Materials and Methods

Videotapes of veterinarian-client-patient interactions in companion animal practice were used. Details of the study design, including sampling strategy and data collection, have been previously described.¹⁷ Briefly, a random sample of 50 veterinarians was recruited from the population of companion animal practitioners in southern Ontario. Participants were contacted by one of the authors (JRS) to inform them of the project, obtain consent, and arrange a site visit. All clients who arrived for a scheduled appointment during the site visit were invited to participate in the study. Fifty veterinarians and 300 veterinary medical appointments were videotaped. For each veterinarian, at least 6 appointments were videotaped, including at least 3 wellness appointments and 3 appointments related to a health problem. Potential contributors to veterinarian visit satisfaction were investigated (Appendix), including practice, veterinarian, client, and pet demographic traits; appointment type; veterinarian personality traits; length of appointment; communication patterns, dynamics, and variables; and emotional tone ratings. The Human Ethics Committee at the University of Guelph approved the research protocol, and Johns Hopkins University Institutional Review Board approval was obtained for analysis of the visit videotapes.

Demographic data—A brief survey was administered to veterinarians and clients to obtain information on demographic traits of participating practices, veterinarians, clients, and pets. Veterinary practice data included the number of veterinarians in the practice, appointment duration, practice type (ie, exclusively small animal or mixed animal practice), and location of the practice (ie, rural, suburban, or urban). Data collected regarding practicing veterinarians included age, gender, and ethnicity. Data on participating clients included how long they had known the veterinarian, number of visits to the veterinarian per year, age, gender, educational background, and household income. Clients were also asked to report the species, breed, sex, and age of their pet and the number of pets in the household.

Appointment type—A wellness appointment was defined as a veterinary encounter with a presumably healthy juvenile, adult, or geriatric dog, cat, or small mammal that had been brought to the veterinary clinic for an annual examination. A problem appointment was defined as a veterinary encounter with a dog, cat, or small mammal with a health-related issue.

Veterinarian personality traits—Self-esteem and empathy were measured as indicators of interactional competence. Self-esteem^21,22 was defined as a global feeling of self-worth or self-acceptance. In social sciences, the Rosenberg self-esteem scale (10 items) is the most widely used instrument to measure self-esteem and is the standard by which new measures are evaluated.^21,22 Each item is scored on a 5-point Likert scale²³ from 0 to 4 (0 = does not describe me well; 4 = describes me well) with a possible total score range from 0 to 40.

Empathy^24–26 was defined as the cognitive capacity to understand another person's needs, an affective sensitivity to a person's feelings, and a behavioral ability to convey understanding to a person. The interpersonal reactivity index²⁶ measures empathy as a multidimensional construct including affective and cognitive components. Of the 4 aspects of empathy measured by the interpersonal reactivity index, 2 dimensions of empathy, perspective taking (the tendency to adopt the point of view of other people [7 items]) and empathetic concern (the tendency to experience feelings of warmth, compassion, and concern for other people [7 items]), were used. Each item was scored on a 5-point Likert scale²³ from 0 to 4 (0 = does not describe me very well; 4 = describes me well).

Veterinarian-client-patient communication—Videotapes of the 300 medical appointments were analyzed by coders trained to reliably apply the RIAS. The RIAS methodology as used in veterinary medicine has been previously described.¹⁷ In brief, the unit of analysis is the smallest segment of speech expressed that conveys a complete thought, usually a simple sentence, a sentence clause, or a single word. Application of codes is exclusive and exhaustive so that every statement is assigned to a single code and all statements by all speakers are coded. Interactions were analyzed in 3 directions: veterinarian to client, client to veterinarian, and veterinarian to patient.

Determining communication patterns—Veterinarian preference for biomedical and biolifestyle-social communication patterns has been reported previously.¹⁸ The conversational emphasis of the biomedical pattern was on veterinarian biomedical question asking (80%) and information giving (92%). In contrast, the focus of the biolifestyle-social pattern was on question asking (48%) and information giving (29%) related to lifestyle activities and social interactions.

Evaluation of communication dynamics—Two measures were used to describe the balance of communication between the veterinarian and client and have been described previously.¹⁸ A verbal dominance score was calculated to assess the balance of the dialogue between the veterinarian and client as the ratio of total number of veterinarian statements divided by the total number of client statements.²⁷ The client-centered score reflects the balance of power between the veterinarian and client in multiple aspects of the clinical interview, including data gathering, education and counseling, relationship building, and establishing a partnership. The client-centered score is the ratio of client-centered statements to veterinarian-centered statements.²⁷

Defining communication composites—The individual communication variables were grouped into communication composites to reflect the 4 functions of the clinical interview (data gathering, client education, responding to emotion, and establishing a working partnership)²⁷ and the content of the medical dialogue. In the veterinary medicine context, the content is classified into 4 areas: biomedical, lifestyle activities, social interactions, and anticipatory guidance topics, reflecting the content-based RIAS codes.¹⁷ The biomedical content area included discussion of the medical condition, diagnosis, treatment, and prognosis. Lifestyle activities included discussion of the pet's exercise regimen, environment, diet, and sleeping habits. Social interactions included discussion of the pet's personality, temperament, or behavior and human-animal and animal-animal interactions. Because of the low frequency of discussion of lifestyle and social topics, these categories were combined. Anticipatory guidance topics incorporated discussion of expectations during normal development of an animal throughout its life stages. Topics included changes in behavior, feeding, sleeping habits, exercise routine, and socialization with people and other animals.

Emotional tone—Coders rated the emotional tone of the veterinarians and clients on the basis of ratings of positive affect, including interest, friendliness, responsiveness, sympathy, and respectfulness (veterinarian and client), and negative affect, including irritation, anxiety, dominance (veterinarian and client), emotional distress (client only), and being hurried (veterinarian only), on a scale from 1 (low) to 5 (high).

Measuring veterinarian visit satisfaction—The dependent variable, veterinarian visit–specific satisfaction, was measured by use of the 20-item physician satisfaction scale developed by Suchman et al.²⁰ One item (“This was a very satisfying visit for me”) evaluates the global visit satisfaction. This instrument assesses 4 dimensions of physician satisfaction: satisfaction with the physician-patient relationship, data-gathering process, effective use of time during the visit, and cooperative nature of the patient. Two modifications were made to reflect the nature of the veterinarian-client-patient relationship, replacing “patient” with “client” and adding a new item: “This patient is pleasant to work with.” All of the items were rated on a Likert scale²³ (1 = strongly disagree; 5 = strongly agree). Veterinarians completed the questionnaire after an encounter.

To evaluate the usefulness and reliability of the physician satisfaction scale in the veterinary context, factor analysis with varimax rotation was conducted, and internal reliability was assessed by use of Cronbach α. Factor analysis is a method to assess whether items in a survey instrument are correlated and conceptually related to each other. Cronbach α is a statistical test of the correlation of items on a scale to determine whether all the items are measuring the same underlying concept.

Statistical analysis—Linear regression was used to study the relationship between potential contributors and global veterinarian visit satisfaction and the 4 subscales: veterinarian-client-patient relationship, data-gathering process, effective use of time, and cooperative nature of the client. The structure of the data set was hierarchic and divided into 2 levels: veterinarian- and visit-level data. General linear mixed models were used to address the multilevel structure of the data. Because previous research¹⁹ identified diversity in veterinarian-client-patient communication in wellness and problem appointments and there was a significant difference in global satisfaction ratings for the 2 appointment types, the data were stratified, and separate models were constructed for wellness (n = 150) and problem visits (150).

Univariate analyses were used to screen variables (cutoff at P < 0.10), then were entered into general linear mixed models (Appendix). On the basis of the univariate analysis, 12 variables were related to the global satisfaction model, 15 to the veterinarian-client-patient relationship model, 14 to the data-gathering process model, 15 to the effective use of time model, and 26 to the cooperative nature of the client model. Backward stepwise elimination was used to further reduce the model, and variables were retained at a generous significance level (P < 0.10) because of the exploratory nature of the study. A random effect term of veterinarian within veterinarian gender was included in all the models to account for clustering of multiple visits per veterinarian. The statistical analyses were performed with statistical software.^a

Results

Demographic data—The full demographic characteristics of the study population were previously published.¹⁸ In summary, of the 50 veterinarians who participated in the study, 24 (48%) were female. Mean age was 41 years (range, 26 to 68 years; SD, 8.15). Forty-three (86%) were Caucasian. Thirty-nine (78%) of the participants worked in multiveterinarian practices. Twenty-four of the 48 (50%) veterinary practices were located in suburban regions. Of the 300 clients, 220 (73%) were female. Mean age of all 300 clients was 43 years (range, 14 to 86 years; SD, 14.09), and the clients came from a variety of socioeconomic and educational backgrounds. Of the 418 pets, 158 (38%) were cats, 255 (61%) were dogs, and 5 (1%) were small mammals (rabbits, guinea pig, ferret, and rat) of various ages and either sex. Forty-five of the 300 (15%) appointments were first-time interactions with the veterinarian.

Factor analysis of the veterinarian visit satisfaction scale—Factor analysis with varimax rotation of the 20 items largely replicated the scale structure of Suchman et al²⁰ with physicians, and 4 dimensions of veterinarian visit–specific satisfaction were identified (Table 1): satisfaction with the veterinarian-client-patient relationship (4 items; Cronbach α = 0.82), data-gathering process (3 items; Cronbach α = 0.69), effective use of time during the visit (3 items; Cronbach α = 0.52), and cooperative nature of the client (5 items; Cronbach α = 0.70). Finally, global satisfaction was assessed on the basis of response to the item “This was a satisfying visit for me,”, on the 5-point Likert scale.²³

Veterinarian personality traits—The overall mean ± SD score for self-esteem was 32.13 ± 5.79 (range, 17 to 40; possible score, 10 to 40). The overall mean ± SD scores for the 2 measures of empathy were 19.62 ± 3.90 (range, 9 to 28; possible score, 7 to 28) for perspective taking and 21.60 ± 3.59 (range, 13 to 28; possible score 7 to 28) for empathetic concern.

Veterinarian satisfaction—Satisfaction was positively skewed, with mean scores close to 4 on a 5-point scale with some variation across the 4 subscales (Table 1). Global visit satisfaction was significantly related to all the subscales and most strongly correlated with the veterinarian-client-patient relationship (Pearson correlation coefficient = 0.58) and data-gathering process (Pearson correlation coefficient = 0.57) subscales. Correlations were somewhat weaker to effective use of time (Pearson correlation coefficient = 0.35) and cooperative nature of the client (Pearson correlation coefficient = 0.37) subscales. The subscales explained 43% of the variance in global visit satisfaction; most of the variance was explained by the veterinarian-client-patient relationship (34%), followed by the data gathering process (8%) and effective use of time (1%). The cooperative nature of the client subscale did not explain any independent variance. Nine of 50 (18%) veterinarians rated all of their visits as satisfactory. The greatest source of variation in global satisfaction occurred within veterinarians across appointments (82%), and the remainder (18%) occurred between veterinarians.

Wellness versus problem appointment visit satisfaction—Satisfaction scores were consistently higher for wellness, compared with problem appointments (Table 2). This difference was significant (P < 0.01) for the global visit satisfaction measure and the cooperative nature of the client subscale. Veterinarian competence differed, and veterinarians felt more confident in wellness (mean ± SD score, 4.69 ± 0.66) than problem appointments (mean ± SD score, 4.51 ± 0.74; P < 0.01).

Veterinarian satisfaction in wellness visits—Several specific elements of client communication were associated with veterinarian satisfaction (Table 3). These include both positive and negative comments (related to global satisfaction) and a greater amount of client conversation overall (related to satisfaction with data gathering). The number of client negative and social statements was inversely related to the measure of satisfaction with the cooperative nature of the client.

Several elements of veterinarian communication were associated with their wellness visit satisfaction. These include lowered verbal dominance and increased positive discussion (satisfaction with the veterinarian-client-patient relationship); fewer orientation and direction statements (satisfaction with data gathering); greater patient education about clinical signs, condition, and treatment (satisfaction with use of time during the visit); and greater social discussion (satisfaction with cooperative nature of the client).

Personality measure correlates—The most consistent association with wellness visit satisfaction was the measure of veterinarian self-esteem, which was significant in 4 of the 5 satisfaction models (global satisfaction, veterinarian-client-patient relationship, data gathering process and effective use of time during the visit subscales). In addition, the measure of empathetic concern was positively correlated with satisfaction with the use of time.

Demographic characteristic correlates—The relationship was more satisfying with a long-term client and in conversations with female clients (mean ± SE score, 4.12 ± 0.07) than with male clients (3.86 ± 0.11). The more visits per year the client made to the veterinarian, the more satisfied the veterinarian was with the cooperative nature of the client. Caucasian veterinarians (mean score, 4.46 ± 0.07) were more satisfied with the client's demanding nature than non-Caucasian veterinarians (4.02 ± 0.18).

Veterinarian satisfaction in problem visits—Specific elements of client communication were associated with veterinarian problem visit satisfaction (Table 4). These included fewer client negative statements and greater rapport building (related to satisfaction with data gathering) and greater client social discussion (related to satisfaction with use of time during the visit) and lower negative emotional ratings (satisfaction with cooperative nature of the client).

Several elements of veterinarian communication were associated with problem visit satisfaction. These include lower negative emotional ratings (global satisfaction), more positive statements and higher positive emotional ratings (satisfaction with the veterinarian-client-patient relationship), and fewer overall veterinarian statements to the client but more statements to the pet (satisfaction with cooperative nature of the client).

Personality measure correlates—The most consistent association with problem visit satisfaction was the measure of veterinarian empathetic concern, which was significant in 4 of the 5 satisfaction models (global satisfaction, veterinarian-client-patient relationship, data-gathering process, and cooperative nature of the client subscales). In addition, the measure of self-esteem was positively correlated with the time subscale.

Demographic correlates—Demographic correlates included long-term client relationship (satisfaction with veterinarian-client-patient relationship), multiple client visits to the veterinarian per year (satisfaction with veterinarian-client-patient relationship and cooperative nature of the client), and multiple pets per visit (satisfaction with veterinarian-client-patient relationship).

Discussion

To our knowledge, the present study represents the first exploratory quantitative study of veterinarian visit satisfaction. Overall, the companion animal veterinarians in this study were highly satisfied with their appointments, with greater satisfaction in wellness than problem appointments. The results of the present study suggest that veterinarian satisfaction is related to communication that builds relationships with clients, expressing empathetic concern, and nurturing veterinarian self-esteem and well-being. With development of healthy self-care routines, veterinarians can create opportunities to reflect and to continue to provide compassionate care to others. The implications extend to overall job satisfaction and its potential link to the health and well-being of individual veterinarians.

The validated physician visit satisfaction scale²⁰ used in the present study appears to be a useful and reliable method of assessing veterinarian visit satisfaction. The strength of the scale was evident in the acceptable measure of internal consistency²⁸ and predictive validity to visit communication dynamics. As with earlier use of the scale with physicians,²⁰ 4 discrete and independent dimensions of veterinarian visit satisfaction were identified. Veterinarian satisfaction with the veterinarian-client-patient relationship and data gathering demonstrated the strongest relationship with global visit satisfaction, as with physicians. The survey was well received by the study veterinarians, demonstrating face validity in that the veterinarians perceived the items to be relevant to veterinary practice. This tool allowed us to measure veterinarian visit satisfaction and to identify personality, sociodemographic, practice, and communication factors that influence veterinarian visit satisfaction.

A majority (74%) of the study veterinarians in companion animal practice were satisfied with their appointments; only 21 (7%) appointments were rated as unsatisfactory. Individual veterinarian ratings of global visit satisfaction differed more across patients and clients than between veterinarians. There was high satisfaction with the 4 dimensions of veterinarian visit satisfaction, including the veterinarian-client-patient relationship, data-gathering process, effective use of time during the visit, and cooperative nature of clients. Visit satisfaction was dependent on the type of appointment; veterinarians reported increased satisfaction with wellness appointments, compared with problem appointments, and the potential contributors to visit satisfaction differed for wellness and problem appointments.

In the present study, veterinarian and client communication behaviors that fostered relationship building most consistently correlated with wellness and problem visit satisfaction. Another relationship indicator was client familiarity with the veterinarian; the longer the duration of the veterinarian-client-patient relationship, the greater the veterinarian's visit satisfaction. Veterinarian positive statements include laughter, compliments, and statements reflecting agreement and approval. These are communication behaviors that build rapport through demonstrating interest, friendliness, and warmth, and are associated with human patient satisfaction^29,30 and subsequently physician satisfaction.³¹ Others have reported that the development of a trusting relationship is a rewarding aspect of veterinary practice.^6–8,16,32 In a study²⁰ of physician-patient interactions, the physician-patient relationship was identified as one of the most important predictors of physician and patient satisfaction.

Self-esteem was the most consistent factor contributing to wellness visit satisfaction, including global satisfaction, quality of the veterinarian-client-patient relationship, data-gathering process, and effective use of time during the visit. Self-esteem is a global feeling of self-worth or self-acceptance, and an overall approval of oneself as a veterinarian is related to positive perceptions of veterinarian-client-patient interactions. Self-respect is an adaptive and self-protective attribute and may serve as a buffer in stressful situations. Research is lacking on doctor self-esteem in medical and veterinary practice. In a study^b of factors relating to physician job satisfaction, self-esteem was identified as a key intrinsic factor. The Brakke management study³³ reported that self-esteem is correlated positively with income. High self-confidence is an important life skill for success in veterinary medicine³⁴ and a vital component of positive learning for veterinary students.³⁵

Empathetic concern was consistently associated with problem visit satisfaction, contributing to global satisfaction, quality of the veterinarian-client-patient relationship, data-gathering process, and veterinarian perception of the nature of the client. In human medicine, clinical empathy is defined as having the capacity to understand the patient's situation, perspective, and feelings (cognitive event), to communicate that understanding and check its accuracy (affective action), and to act on that understanding with the patient in a helpful way (affective action).³⁶ As measured in the present study, empathetic concern is a cognitive event based on sensitivity and other-oriented emotional responses.²⁶ Empathy is one of the tools for providing emotional social support (including caring, reassurance, and trust), creating opportunities for emotional expression and mutual understanding.³⁷

An effect model of empathic communication in clinical encounters in human medicine describes how clinical empathy can achieve improved patient outcomes.³⁶ Expressing empathy fulfills the patient's basic human need to be listened to, understood, accepted, and validated, which serves as the foundation for achieving effective clinical outcomes.³⁶ From the physician perspective, expressing empathy enables patients to share their concerns, enhancing diagnostic accuracy and creating shared understanding and an active and informed role for patients. Studies of physician-patient communication indicate that expressing empathy improves patient satisfaction^29,30 and adherence³⁸ and leads to fewer malpractice complaints.^39,40

In veterinary medicine, rapport-building behaviors, such as empathy, are highly valued by clients, and clients expect their veterinarians to be compassionate in caring for animals and respectful in their client interactions.⁴¹ Empathy is an expected attribute of veterinary graduates^42,43; however, a previous study¹⁸ found that empathy statements are underused in veterinary visits, with expressions of empathy in only 7% of appointments. Empathy is a key skill for building social connections, and social relationships are integral to high levels of happiness and satisfaction. Conversely, negative interactions are a source of psychological stress.³⁷

Differences in veterinarian-client-patient communication may account for some of the variation in veterinarian visit satisfaction ratings between wellness and problem appointments. On the basis of results of a previous study,¹⁹ wellness appointments were characterized as relationship centered with an emphasis on rapport building, social conversation, and attentiveness to the pet in a relaxed and friendly atmosphere. Problem appointments were characterized as narrowly biomedical and, in some cases, with a tense emotional atmosphere. Similar findings have been reported in studies^44–46 of physician-patient communication and patient satisfaction. Physicians reported that it was more satisfying to work with healthy patients. In visits with sick patients, physicians engaged in less social conversation, expressed more disagreement, and conveyed negative emotions.⁴⁴ From the client perspective, there is evidence that clients may also find wellness visits more satisfying than problem visits.³²

Veterinarians perceived clients to be more demanding in problem appointments, and emotional tone was identified as a contributor to problem visit satisfaction. Veterinarian expression of negative emotions reduced veterinarian global satisfaction, and expression of positive emotions enhanced the quality of the veterinarian-client-patient relationship. When clients expressed negative emotions, they were more likely to be perceived as demanding. A previous study¹⁹ identified differences in client emotional tone in wellness and problem appointments. In problem appointments, clients expressed criticism and concern and were rated as anxious and emotionally distressed by coders. In wellness appointments, clients expressed laughter, engaged in social conversation, and were rated as respectful by coders. Reciprocity theory helps to explain the differences in veterinarian and client communication behaviors in wellness and problem appointments. Aspects of nonverbal (ie, smiling, eye contact, and posture) and verbal communication and emotional tone are typically reciprocated or matched in social interactions.⁴⁷ Positive statements and facial expressions are often reciprocated with warmth, and reserved behaviors are reciprocated with coolness or aloofness.

The growing human-animal bond presents challenges. Eighty-five percent of pet owners surveyed in the United States consider their pets to be a member of the family.^16,41 It is difficult when a companion animal is ill, and as a result, clients may appear to be unreasonably demanding. Client behaviors that are often labeled as difficult include expressions of grief, concern, anxiety, guilt, or anger.⁴⁸ Delivering bad news and discussing euthanasia with a client are difficult and stressful tasks.^13,49 Lastly, financial issues are more likely to arise in problem visits and can be a major source of stress for both the veterinarian and client.^11,12,50

In addition to different client expectations in wellness and problem visits, veterinarians felt less competent in problem appointments. Although this difference was significant and might be expected, the magnitude of the difference was quite small. Wellness appointments are typically routine in nature, and problem appointments can be complex and demanding. Today, veterinary clients are more educated and have high expectations,^15,50,51 and veterinarians may not feel comfortable addressing the increasing demands and questions of clients with sick pets. With the tremendous growth in medical knowledge, veterinarians face increased pressure to keep abreast of advances in medicine. In addition, veterinarians may feel that they have not been adequately trained to handle certain medical or surgical problems. Veterinarians may feel challenged when managing patients with relatively complex medical and surgical problems, thus decreasing satisfaction.

In a review of physician satisfaction,⁵² the amount of time allotted for each encounter was identified as a strong predictor of physician satisfaction. In the present study, the total length of the appointment was not related to visit satisfaction in either wellness or problem appointments. Another related finding was that there was no difference in veterinarian responses to the visit satisfaction time-related survey items in wellness and problem appointments. It was surprising that length of appointment was not identified as a significant factor related to visit satisfaction given that it was anticipated that veterinarians might feel that they did not have enough time for problem appointments, compared with wellness appointments.

The most common client demographic factors that contributed to veterinarian visit satisfaction in the present study were the long-term relationship with the veterinarian and the number of client visits per year to the veterinarian. Both of these variables are indicators of an established relationship that seemed to promote rapport, ease, and comfort in the veterinarian-client-patient interaction. In wellness visits, veterinarians were more satisfied with relationships with female clients. The majority (77%) of the clients in the study were female. In human medicine, there is evidence that patient behavior largely reciprocates physician behaviors⁵³ and female patients foster a more patient-centered and participatory interaction with their physician.⁵⁴ Although it has not been investigated, such behaviors may enhance physician satisfaction with female patients. In wellness visits, Caucasian veterinarians were more comfortable in working with demanding clients than were non-Caucasian veterinarians. There was minimal ethnic diversity in the veterinarian sample in this study; 43 of 50 (86%) veterinarians were Caucasian. Cultural competence is the ability to be aware of your own cultural worldview, to understand cultural differences and practices of others, and to communicate effectively with people of different cultures.⁵⁵ Developing multicultural approaches to providing veterinary services is integral to caring for a highly diverse clientele.

The present study represents a first attempt to quantitatively measure veterinarian visit satisfaction and to explore factors that contribute to veterinarian visit satisfaction, including veterinarian, client, and patient characteristics. The first limitation of the study relates to the sampling strategy. Caution is necessary in generalizing these findings to the veterinary profession as a whole. The participants in this study were companion animal veterinarians in southern Ontario, and it is likely that the findings would differ for veterinarians in other regions and areas of practice. In future studies, larger sample sizes or purposeful sampling may be required to achieve greater distribution of veterinarian satisfaction ratings and obtain a greater number of unsatisfying visits. Even though the number of unsatisfying visits was low (21/300 [7%]), informative models were developed. Only 6 appointments were videotaped for each veterinarian, and in the present study and a previous study,¹⁸ the greatest source of variation in communication was within veterinarian. Thus, in future studies, sampling and data collection techniques should incorporate a larger number of visits per veterinarian.

The second limitation is the challenge of measuring a multifactorial sociological construct, such as satisfaction, in a linear manner. Veterinarian visit satisfaction is a complex phenomenon related to veterinarian individual values, attitudes, and expectations of the encounter. It is unlikely that the data collection methods used captured all the factors that contribute to the complexities of veterinarian-client-pet interactions and visit satisfaction. Because of the large number of contributors and reliance on variable screening techniques, it is possible that we may not have included key measured variables in the model. Few researchers have investigated veterinarian visit satisfaction, and additional qualitative analyses, such as in-depth post-appointment interviews or focus groups with veterinarians, may create a greater understanding of the satisfaction construct for future quantitative studies.

The third limitation was that we measured veterinarian visit–specific satisfaction, and the scale did not include other essential external factors related to overall job satisfaction, such as work demands (ie, hours, caseload, or on-call responsibilities), environment (ie, staff relationships and teamwork), and facility and equipment. It would be of interest to broaden the scope of investigation to further characterize veterinarian job satisfaction and study the relationship between visit satisfaction and overall job satisfaction.

An original objective of the larger study was to assess agreement between veterinarian visit satisfaction and client visit satisfaction. Client satisfaction with the veterinarian-client-patient interaction was measured; however, given the lack of variation in client responses (ie, highly positive skewed responses), additional analyses could not be performed. Similar methodological challenges have been reported in measuring patient satisfaction in human medicine.^56–59 Recently, a reliable and valid measure of client satisfaction was developed³² that could be implemented in future studies.