1. Introduction
In recent years, there have been significant diagnostic and therapeutic advances in small animal medicine. Veterinary oncologists can now diagnose cancer in companion animals with advanced imaging techniques, like computer tomography [
1], and then treat it using therapeutic methods, such as chemotherapy and radiotherapy. Hip arthroplasty, heart valve replacement, dialysis, imaging, and specialties, such as cardiology and neurology, are becoming standard. In short, modern companion animal veterinary medicine provides many treatment options that are not far behind those offered in human medicine. For example, cancer in small animals can not only be detected at an earlier stage with advanced diagnostic imaging techniques like computer tomography [
1]; it can also be treated with various therapeutic methods, such as chemotherapy and radiotherapy, which are increasingly being used to prolong the lives of affected animals.
There is no doubt that animal patients can benefit from improved diagnostics and therapies if they are used in the animal’s best interests. To act in the best interests of an animal can be understood as a matter of promoting its health and improving its quality of life [
2]. In the literature proper consideration of these patient-centered factors is often presented as fundamental [
3,
4,
5], and some authors make a normative claim in favor of a strong patient advocacy in companion animal medicine [
6,
7,
8,
9,
10]. For example, the philosopher Simon Coghlan points out that the significant status of companion animals and the role-based duties of veterinarians to their patients combine to justify the prioritization of the best interest principle during patient care. He concludes that veterinarians “have ‘primary obligation’ and ‘first allegiance’ to their animal patients rather than to other parties, such as their clients or employers” [
9].
However, recent empirical investigations question whether this view is realistic and indicate that decision-making processes in small animal practice are strongly influenced by contextual factors related to the client, the veterinarian, professional colleagues and the working environment [
11,
12,
13,
14,
15,
16]. This can create moral dilemmas for veterinary professionals [
17]. The contextual factors may collide with the veterinarians’ supposed advocatory role, and when they do it will be morally challenging for the veterinarian to comply with the best interest principle.
This can be seen in a study conducted in the UK, where small animal veterinarians indicated that financial limitations, the clients’ preference to continue treatment, and convenience euthanasia were creating ethical dilemmas in veterinarians’ daily working life [
14]. Other empirical studies have highlighted the importance of upfront discussions of costs during patient care [
15] and looked at the complexities of dealing with financially limited clients [
12]. The handling of such clients is perceived as especially stressful [
11,
14], as this restricts the provision of best care to the animal patient, but also has negative effects on the veterinary clinic’s own financial viability. The combination of economic factors and veterinarian’s position as a service provider is also important, and is often-discussed. For example, in 2012 the Austrian Institute for Economic Research published a report on the economic basis for strategic decisions on future aspects of veterinary medicine. The report shows that veterinary medicine is predominantly a service provider, and that it, therefore, depends closely on the development of downstream sectors and private demand [
18]. In light of this, veterinarians are obliged to consider economic aspects and act as service providers at the same time.
In cases where clients have a strong emotional bond with their animals, the client’s expectations and wishes can lead to especially complex and emotionally driven decision-making. A study of companion animal ownership conducted in Austria found that strong emotional bonds between Austrians and their pets had become more common in the period 2012–2017. In 2017, of a total of 1009 interviewees (90%) stated that they see their dogs and cats as good friends (up 7% since 2012). In all 74% of respondents revealed that their animal has the status of a family member (up 9% since 2012) [
19].
Strong relationships become more complex if the animal contracts a disease and its care becomes a task for the owner [
20]. In a US study, veterinarians agreed that giving due consideration to the bonding between clients and their animals has a positive effect, and that they are more successful when they recognize and facilitate the human-animal-bond [
16]. By contrast, some authors associate strong human-animal bonds with negative consequences such as overtreatment and prolongation of animal suffering as a side-effect of the owner’s request for further therapy [
21,
22,
23,
24].
These findings make it clear that it can be a challenge for veterinarians to maintain their role as an animal advocate in veterinary practice. With more advanced, and often more costly, treatments, the challenges may intensify. Arguably, this development has been coming for many years: already, in 1995, Tannenbaum stated that the intensity and severity of ethical challenges would increase with the establishment of advanced methods and technologies in veterinary practice [
25]. Additionally, he argued that the issue of overtreatment and client finance and time limits would confront veterinary professionals with especially difficult ethical issues.
It should also be borne in mind that the veterinary profession appears to be witnessing growing specialization—a development which can be partly ascribed to the ever-growing implementation of advanced technologies and methods [
26,
27]. Although specialization brings benefits such as improved knowledge, it also potentially generates issues between involved parties [
27]. The existence of different knowledge bases, and specialists with their own expertise, leads to an increasing compartmentalization of the profession, which, in turn, can introduce different, or even conflicting, interests in the course of veterinary treatments. Disagreements can emerge between specialist veterinarians working in different fields at the same clinic, and of course they can also arise between general practitioners and specialist veterinarians in the course of the referral process.
The hypothesis of the present paper is that advanced diagnostics and therapies in small veterinary practice add to the complexity of decision-making during patient care. To the authors’ knowledge, the assumption that the number and severity of ethically challenging situations in the veterinary practice increases as a result of use of advanced diagnostics and therapies has not yet been verified empirically in a systematic way. It is the purpose of this paper to fill this gap in our understanding of veterinary practice.
A focus group study with small animal veterinarians was carried out in Austria to gather insights into this issue. Veterinarians working in Austria offer a suitable study population for this explorative study, since Austria offers a variety of business models within the veterinary profession. Thus, besides the university hospital and small practices, Austria has both corporate chains of clinics, like those in the UK, and privately-owned clinics of various sizes.
A qualitative method was chosen because no studies to date have looked at advanced veterinary medicine and the challenges it introduces in practice. Focus group discussions, unlike other qualitative methods such as semi-structured individual interviews, also allow the differing attitudes and beliefs of veterinarians to be revealed more fully if there is a lively debate on everyday challenges in the profession. In addition, the mutual exchange of views helps to pinpoint not only commonalities, but also differences in opinion and uncertainties among participants [
28,
29].
The aims of the study were: first, to identify the patient-centered factors which veterinarians see as relevant during patient care; second, to investigate other contextual factors that influence decision-making processes during patient care in general; and third, to explore these other factors and their effects in the specific circumstances of advanced veterinary practice.
2. Materials and Methods
A total of six focus group discussions with 4–7 participants, all of whom were small animal veterinarians, were conducted in Austria in March and April, 2018 (n = 32).
2.1. Overview of the Number of Austrian Small Animal Veterinarians and the Selection of Participants
Approximate numbers of veterinarians, practices, and clinics in Austria working with small animals were determined using multiple sources, whereas practices differ from clinics by the number of veterinarians (practices: 1–3 veterinarians; clinics: more than three veterinarians) and specialization (practices: generalists and basic equipment; clinics: higher degree of specialization and more advanced equipment). Thus the Austrian Association of Small Animal Veterinarians (VÖK) (register contains: 1327 veterinarians/status Nov 2017), a large pharmacy group (list of 792 small animal practices and clinics working with small animals/status Nov 2017) and a comprehensive search of an online classified directory (778 Austrian practices and clinics working with small animals were found/status Nov 2017) provided an overview of veterinarians, as well as practices and clinics in the field of small animal medicine.
The six focus group discussions were planned so as to include veterinarians with various positions and roles in practices and clinics in the small animal sector in Austria, as we hypothesized that these different positions may affect attitudes and decision-making. Thus, the sampling strategy involved participants from several strata: a) current occupation—divided according to hierarchical position (practice owner or employee) or level of specialization; b) availability of equipment; c) number of colleagues; d) degree of urbanization (from rural region up to capital city (Vienna)); and e) working place (federal state). Recruitment to the focus groups was organized so that the groups were homogenous with respect to the current occupation of the participants (
Table 1). Group 1 and Group 3 included specialist veterinarians working at the university hospital in Vienna and at several referral clinics in Austria, respectively. Group 2 included managers and clinic owners. Groups 4, 5, and 6 contained general practitioners who were self-employed with no or very few employed veterinarians. Further details regarding the distribution of the four other factors (i.e., those listed in b), c), d), and e) above) within and between the groups are set out in
Table 1. Veterinarians were only recruited due to their involvement in small animal medicine. Thus, out of the 32 veterinarians, 30 participants worked solely with small animals. Only one veterinarian also worked with farm animals and one participant also worked as an official veterinarian.
2.2. Recruitment Process and the Study Participants
In mid-January 2018, invitations were emailed to 60 selected veterinarians on the basis of the above-mentioned criteria with the aim of including 10 veterinarians in each group. All of the veterinarians were personally contacted by telephone two weeks later, at the end of January 2018. Suitable replacement candidates were selected if veterinarians declined the invitation or did not react within two weeks of the emails being sent out. The invitation and recruiting process was closed when at least five participants per group had confirmed their participation: this turned out to be at the end of February for Groups 1–5 and end of March for Group 6. Reminder emails were sent to all participants 3–4 days before the scheduled focus group discussions. In total, 114 veterinarians were contacted during the recruitment process, and 36 confirmed their participation. Four veterinarians could not participate owing to unforeseen events (three were ill and the car of the fourth broke down), so ultimately 32 veterinarians participated.
Table 1 provides a general overview of the participants in all six focus groups. The veterinarians did not receive an allowance or an honorarium. However, they were informed that their travel expenses would be reimbursed.
2.3. Structure of Focus Group Discussions
All six focus group discussions were conducted in German. The shortest was 2 hours and 24 minutes. The longest was 2 hours and 37 minutes. All discussion in the groups followed a semi-structured interview guide. This consisted of four themes structured according to the so-called ‘funnel approach’, i.e., it started with general questions about patient care in veterinary medicine and moved on to more specific questions. Depending on the group, the formulation of individual questions was slightly changed and adapted to suit the participants and their working background (
Supplementary Files 1–3). However, the process of each group discussion was the same in terms of structure and overall content. Throughout the discussions, the moderator, who ensured that all participants had the opportunity to speak and be heard, took a neutral position.
The steps and the contents of the interview guide were piloted on four veterinarian test persons. These test runs did not aim to simulate a group discussion. They were designed to evaluate and verify the clarity of the interview guide questions and topics, and to see whether the questions triggered relevant thoughts and responses. Comments and suggestions made by the test persons were incorporated into the final versions of interview guides.
After a short introductory round (min. duration: nine minutes; max. duration: 28 minutes), the first part of the interview guide aimed to elicit an overall impression of important aspects of patient care in small animal practice (Theme 1). Further, participants were required to order the interests of each of the three key stakeholders: veterinarian, animal, and client. Challenges related to the clients, and their expectations given the diagnostic and therapeutic possibilities, were identified (min.: 26 minutes; max.: 47 minutes). The second part of the interview guide aimed to direct the discussion towards the topic of advanced diagnostic and therapy in veterinary medicine by identifying related uncertainties (Theme 2). Additionally, participants were asked to describe cases where they thought veterinarians go too far in diagnostics and therapy (min.: 29 minutes; max.: 48 minutes). During the third part, veterinarians were introduced to three newspaper headlines which brought out the issue of advanced diagnostics and therapy in veterinary medicine in a thought-provoking way (Theme 3). Using the newspaper headlines, the discussion was elevated from the veterinarian-client-animal context to a social context and social discourse. The overall aim was to identify attitudes to the headlines, and to explicate possible divergent attitudes to advanced methods in relation to specific fields of specialization (min.: 15 minutes; max.: 28 minutes). The fourth part was structured around three designed case vignettes. These aimed to elicit responses to different moral dilemmas occurring in the context of advanced veterinary medicine (Theme 4). The aim was to see how veterinarians would handle such situations, and the extent to which factors relating to the animal, the client’s characteristics, and the veterinarian, as well as the working environment, determined decision-making processes (min.: 29 minutes; max.: 37 minutes).
In addition to the moderator (HG), a second person from the project (SS) was present at each discussion to take notes and, if necessary, ask interposed questions. Before recording started, each participant signed a consent form and was informed that all recordings would be treated confidentially. Ethical approval was obtained through the Ethics Committee of the Medical University of Vienna.
2.4. Data Analysis
Recordings of all six focus groups were transcribed verbatim and coded using the MAXQDA 12.0 software program (Berlin, Germany). Following the template organizing style [
30], categories and codes were formulated based on the four themes and key aspects of the interview guide, the research questions and hypotheses of the project. A first cycle of coding and a second cycle of coding were conducted for the analysis of the data gathered from the six focus groups [
31]. Using a deductive approach, the overall aim of the first cycle of coding was to summarize segments of data and categorize similar data units [
31]. The initial code list for the first cycle contained six categories with a total of 24 codes. During first cycle of coding this initial list was adjusted: new codes and categories were added, and other codes that had become non-applicable or redundant were deleted. These alterations chiefly followed an inductive approach based on the gathered data. The final version of the code list included seven categories with 28 codes (
Supplementary File 4). Mainly descriptive coding, hypothesis coding and holistic coding were used to organize and summarize the text segments [
31]. The coding process was mainly done with the transcribed text. Only if uncertainties arose (e.g., concerning negative or positive meanings of statements), the coder (SS) resorted to the recordings. Codes and ascribed segments of data were continuously discussed by the project team (SS, PS, TL, and HG) in order to ensure the relevance of codes, especially during the first coding cycle. In a second cycle of coding, the initial results of the analysis were grouped into smaller categories and clusters to obtain more meaningful units for subsequent content analysis [
31]. This was a qualitative social science study where it is not an ambition to make statistical generalizations about a background population. Rather, the aim is to obtain open-ended and in-depth accounts of beliefs, attitudes, everyday practices, and decisions.
4. Discussion
Our current understanding of the various effects of implementation of new methods and technologies in veterinary medicine is largely anecdotal. This is the first time that empirical findings on the veterinary experience have been collected and analyzed in a way that helps us to understand: a) the patient-centered factors which impact on veterinarians during patient care; b) the other contextual factors influencing veterinary decision-makings in general; and c) specific knock-on effects of advances in small animal practice. In this section, the findings of the present study are considered in relation to relevant published literature. It is pointed out where our data support or add to existing knowledge and where they contrast with earlier findings or assumptions.
The normative claim that veterinarians should prioritize the animal patient’s interests in decision-making processes has been a central concern in recent literature [
5,
7,
10]. Empirical findings also confirm that veterinary clients support the notion that it is the role of the veterinarian to advocate in the patient’s best interests. Thus, Hughes and colleagues found in their study of British and Australian clients that animal owners consider a commitment to the patient’s welfare and quality of life to be the most important goal that veterinarians
should pursue [
32]. However, a question arises about the extent to which professionals
can adhere to such normative demands under everyday clinical circumstances [
33,
34]. Although our results indicated that modern developments in veterinary medicine offer increasingly effective ways to serve the health interests of animals with improved levels of patient care, we also found that a number of contextual factors and effects of advanced medicine push in the opposite direction and prevent veterinarians from focusing solely on the best interest of their patients, and that these factors generally lie beyond the veterinarian’s own control.
The participants of all of our focus groups confirmed that clients with limited funds present an everyday challenge in the veterinarian’s working life. This is in line with other studies, which show that the issue of the client’s ability to pay is a frequent problem and creates economic, as well as moral, challenges for professionals [
11,
12,
14,
15,
35]. For instance, in a focus group study conducted in the US, Coe and colleagues considered financial aspects of animal patient care with invited veterinarians and clients [
15]. Their results show that veterinarians find it challenging when patient care is highly dependent on the financial situation of the client and, connectedly, his or her willingness to agree on treatment. Our findings add to this conclusion. They indicate that the implementation of cost-intensive methods and technologies exacerbates the problem presented by clients with limited funds in modern small animal practice, and that veterinarians are worried about their increasing dependency on clients with sufficient money to pay for sophisticated procedures.
Interestingly, Kogan and colleagues found that most of the veterinarians they surveyed offered discounts on veterinary services and products on a regular basis in order to provide the best possible solution and care for their patients [
36]. This finding was not confirmed by our study. Although the participants in the focus groups we ran explained that they work increasingly in a multi-tier health care system due to the increase of cost-intensive diagnostics and therapies, they focused mainly on finding solutions adapted to the financial situations of the client—they did not, in other words, provide discounts or pro-bono services on a regular basis. This may be connected with the veterinarians’ own financial needs: it may be that they are simply seeking to fund the purchase of expensive technical devices through client payments. A further reason could be that veterinarians see a risk that clients will exploit their good nature and keep asking for reduced prices—the news will likely get around and encourage those requests.
It was expected that in the focus group discussions, the issue of how to finance advanced diagnostics and treatments in small animal practice would be closely tied to questions about pet insurance. However, this was not confirmed: the topic of pet insurance was not at all prominent in the discussions. This may be due to the fact that, in Austria, the market in pet insurance is relatively undeveloped. It is estimated that the number of insured animals is (far) below 10% [
37]. This is in stark contrast with the situation in other countries. For instance, almost 80% of dogs in Sweden are insured [
38]. In the UK, in 2017, there are about 80 providers of pet insurance and demand is increasing [
39].
The market for pet insurance in Austria is surely set to grow. Since little research has been conducted to date on the impact of insurance on veterinarians’ daily working life, further investigation into the extent to which Austrian pet insurance might deal with the problem of clients with limited funds, leading to relief not only on the client’s side, but also for the veterinarian, is certainly needed. Interestingly, Coe and colleagues found that US veterinarians were worried that American pet insurance has different programs covering different kinds of veterinary cost—the speculation was that this could indirectly influence veterinarians’ provision of patient care [
15]. This potentially adverse effects of pet insurance needs to be considered. Cooperation between insurance providers and veterinary associations might offer a suitable way to deal with the concerns mentioned by US veterinarians during the process of market introduction.
Turning to the veterinarians’ discussion, in our study, of clients’ levels of knowledge, use of the internet and related expectations, our data suggest that the internet and social media are indeed having an impact on veterinary practice. The ready availability of information via the Internet leads to high information flow and causes different expectations on the clients’ side [
40]. In line with Clarke, our results indicate that client research using “Dr. Google” puts pressure on veterinarians and challenges them during consultations [
41]. Relatedly, Knights and Clarke have found that the availability of various media sources means that veterinarians are subjected to a high degree of judgment and assessment—their performance is constantly evaluated by “others” [
42]. The veterinarians surveyed by Knights and Clarke expressed concerns especially about complaints via “virtual channels”. Given these empirical findings, we suggest that social media, websites, and the use of “Dr. Google” should play a larger role in future debates about modern veterinary practice. There is an increasing need to use the internet and other new media to meet client expectations—to market veterinary services and alert clients to special offers, for example. At the same time, veterinarians must consider how best to deal with inflated or skewed expectations among clients caused by the combination of new technical possibilities and the unfiltered information flow from the internet.
In keeping with previous studies [
14,
16], the knock-on effects of close emotional bonds between clients and their animals were frequently discussed in all of our focus groups. Although such bonds can have a positive effect during patient care—for example, because clients are more willing to pay for costly diagnostics and therapies [
43]—we were not surprised to find that they can also lead to problematic overtreatment. Our analysis shows that the problem of overtreatment is accentuated by new technologies and methods, and is perceived as quite challenging. At this juncture, veterinarians working at the university hospital explicitly mentioned that the status of patients as family members, as well as close emotional relationships, leads to higher client expectations about the care of their animals. Presumably, veterinarians working in well-equipped clinics are particularly likely to be confronted with such increasing client expectations, because they can deliver the highest levels of treatment.
A further insight given by our findings relates to the process of referring patients and the increasing specialization of the veterinary profession. Relatively few studies [
44,
45,
46,
47] have examined various factors in the veterinary referral process. A recently published focus group study with equine veterinarians found that the relationship between the client and the referring veterinarian, the involvement of the referring veterinarian, good mechanisms of communication, and a collegial relationship between the general practitioners and specialist, are crucial aspects for a good referral process [
44]. The small animal veterinarians also indicated that a good and trustful relationship is fundamental to a good referral process. However, our results go further when it comes to advances in veterinary medicine. For they reveal that both general practitioners and specialists believe that that the use of modern technologies and methods increasingly requires detailed knowledge and time. Those working as general practitioners indicated that they felt relief when referring patients to specialists in cases where the limits of their equipment and professional knowledge were being tested. Such a back-up from a university or a referral clinic leads to more security in general practice by allowing practitioners to define clear limits to their competencies. Hence, veterinarians were aware of their different roles and responsibilities, and the relations between these and their own degrees of specialization and institutional backgrounds.
A key hypothesis of this study was that advanced veterinary medicine adds to the complexity of decision-making, and that this complexity explains in part why patient care is experienced as morally challenging by veterinarians. We found that veterinarians are particularly likely to face moral challenges where they are not able to comply with patient-centered demands. We do not, of course, dispute the normative claim that small animal practice should be patient-centered, and that veterinarians should play an advocatory role. Our point is rather that the findings presented in our study suggest that veterinarians cannot always follow this norm in their daily work. We see a danger that a moralizing approach to small animal practitioners claiming that they must give priority to the best interest principle during animal patient care will simply increase levels of stress within the profession without really helping any patients.
Although it is a strength of the present study that participants in it were carefully selected through a thorough search of the Austrian population of small animal veterinarians, the study also has limitations. The focus group method can create bias when strong opinion-makers in the group dominate the discussion. Additionally, the moderator may steer the discussion, knowingly or unknowingly, in a direction which delivers desired responses, or avoids unwanted outcomes. In the present study, we attempted to minimize bias by conducting several discussion groups, by instructing the moderator to follow an interview-guide, and by ensuring that the moderator was accompanied by a second person from the project, who observed procedure and thematic development. The fact that the study was carried out in Austria may also mean that some of the results will be less relevant in other countries, because of cross-country differences in the institutional set-up of small animal practices—the comparatively low rate of pet insurance in Austria is an obvious example here.
Focus group studies are explorative in nature: they offer an opportunity to generate hypotheses rather than test them. Therefore, we recommend that a quantitative study—e.g., a questionnaire-based survey—should be undertaken to provide representative results relating to the themes presented here. Additionally, further research on this subject could focus on cross-country disparities. It could compare the effect of different legal backgrounds, different organizational structures in small animal practice (e.g., private practices and corporate chains), and different professional norms, as these emerge in national comparisons.