A web-based questionnaire (Supplementary Table 1 sheet Overall) was designed using Netigate (23). The cross-sectional survey targeted mainly veterinarians in current or former clinical practice. Before launching it was pretested with four individuals and edited. Human ethical permit was not necessary according to rules of the Swedish Ethical Review Authority (24), as the questionnaire was anonymous and contained no sensitive personal data. Questions were posed in Swedish, and the questions have been translated for this presentation (Supplementary Table 1). Respondents gave consent to being included by answering the questionnaire.

We designed questions through discussion within, and outside of, the research team. The questions were mainly closed with Likert-scale response options, along with seven open-ended questions allowing respondents to elaborate on their answers. Free-text responses are not used in the current presentation. The option ‘cannot evaluate’ was also provided. The questionnaire was organised into 11 areas (Supplementary Table 1). One area (no 9) did not cover questions relating to the VDB and will be presented separately (whether veterinarians report animal owners to the County Administrative Board).

These areas were selected based on providing background information (areas 1–3), general questions on how veterinarians both with and without previous sanctions experience the VDB (areas 4–5) and questions on how veterinarians would receive owners with previous complaints filed (area 6). The next area was related specifically to veterinarians having had complaints filed (area 7). Then we wanted to gain information on what was perceived to lead to complaints (area 8) and finally question on how a well-working supervision could work (area 10).

The questionnaire was open from 11 December 2024 to 15 February 2025. The link to the questionnaire, together with an invitation to participate, was distributed through emails to members in The Swedish Veterinary Association (11 December 2024, 2,400 active members) and through the Swedish private Facebook sites ‘peptalk för veterinärer’ (7 January 2025, 3,400 members), ‘veterinärmedicin stordjur’ (10 January 2025, 2,500 members) and ‘veterinärmedicin smådjur’ (31 January 2025, 3,000 members). A reminder was sent out to the members on 17 January 2025.

Data were downloaded via the Netigate website as Excel files and processed in Matlab (version R2024b, Mathworks, Natick, MA, USA) using custom-written scripts. For most questions all answers were included, also from respondents not completing the questionnaire (note that a completed questionnaire did not necessarily contain answers to all questions, as responses were not obligatory). Exceptions from this was when questions were only relevant to subsets of the population. To evaluate the impact of including partial responses, percentages were compared between categories for all and answers from completed questionnaires (where the respondent finished the questionnaire by clicking the ending option). Supplementary Table 1 (sheet overall) shows that for only 6.3% of 379 analysed categories, the responses differed more than 1 percentage, indicating that this decision had a minor impact on the results. This indicates that the proportions for all alternatives were similar in the whole sample and the subsample with the completed answers.

All variables were categorical or from Likert scales, in both cases treated as categorical. For evaluating whether all response alternatives were equally common or not, 95% binomial confidence intervals (95% CIs) were calculated. Alternatives such as ‘cannot evaluate’ or ‘do not know’ have been included in the statistics.

Questions on perceptions, opinions, experiences and knowledge about the VDB were tabulated against gender, duration of work experience, whether having left clinical work, size/organisation of workplace, whether having complaints filed (Supplementary Table 1) and for those with complaints filed were acquitted, versus given a warning or a reprimand.

There were 1,054 respondents initiating the questionnaire (answering at least one question) and 819 respondents had clicked to end the questionnaire, i.e., the questionnaire was ‘completed’. For the completed answers the time to answer ranged from 2 min and 17 s up to 140 min and 11 s. The median response duration was 17 min and 34 s. All answers when provided were used, if not otherwise stated (see Supplementary Table 1). To minimize drop-out, answers were not obligatory for any question. Hence, there were different numbers of responses for different questions. Also, to aid for respondents the alternative ‘cannot evaluate’ was frequently introduced into the questions. Supplementary Table 1 shows total results, both with and without stratification by several variables (e.g., gender, workplace type, complaints filed, switched to non-clinical work), including graphs for each question for the stratified responses.

Most respondents were women (82.3%, Table 1). Most respondents had worked for over 20 years in the veterinary clinical profession (36.4%), followed by 11–20 years (31.2%) and 1–10 years (30.7%). Within the group of women, those with 1–10 years, 11–20 years and over 20 years of experience were represented by equal shares (32.1–33.6%). Of all men, 58.0% had worked >20 years, 24.4% 11–20 years and 16.5% for 1–10 years. Most respondents were educated in Sweden (73.5%) (Table 1). Of the 1,034 respondents that provided at least one species common in their practice, 84% of the respondents attended dogs, followed by cats (82%), horses (35%), small mammals (26%), large ruminants (21%), small ruminants (14%), ‘caged’ birds (4%) and reptiles (2%).

Of 1,018 respondent 17.2% had left clinical work. In most cases, 62.3% (of n = 167) the VDB had no influence on the decision to leave clinical work, while for the rest of respondents (37.7% of the ones leaving and 6.2% of all [n = 1,018]) the VDB was considered to have had small or some impact (Figure 1).

Most respondents (47.7%) worked in enterprises that owned a maximum of 5 clinics (Table 1), 38.5% in enterprises owning more than 5 clinics and 13.8% were hired by the state or were district veterinary officers (25). In total, 74.2% stated they did not own their workplace enterprise and 25.8% that they did. In 62.0% the workplace was staffed by more than 8, in 20.0% by 1–3 and in 18.0% by 4–8 persons. Regarding enjoying work, 10.2% stated that they did not enjoy work (combing the 3 first categories) (Figure 1). Combining the first 3 categories for having influence on questions of interest, 25.2% felt they did not have influence. The different seven alternatives available for whether worrying about having complaints filed were evenly filled out, with 40.9% tending to worry (combining the last 3 categories) (Figure 1). The answers regarding having changed from clinical work were tabulated against type of workplace (972 respondents, Supplementary Table 1- sheet LeftVsWorkPlace). It was found that those affiliated with DV had changed from clinical work to a much high degree than those in working in small or larger companies (DV 38.5% [95% CI; 30.3–47.3], clinics owned by companies owning >5 clinics 9.7% [95% CI; 6.9–13.1] and smaller clinics 14.2% [95% CI; 11.2–17.7]).

Following cases from the VDB, and perceptions about the processes at the VDB (area 4).

Annually, very few respondent did request case verdicts from the VDB (3.2% of 954; 95% CI; 2.2–4.6), while 77.8% ([95% CI; 75.0–80.4] of 950) regularly read about cases in The Swedish Veterinary Journal (26). For the five questions concerning perceptions of the work of the VDB (Figure 2), many respondent answered ‘cannot evaluate’ (33–61%), while the second most common category was the middle category ‘agree partially’, concerning whether cases are well investigated, whether expert opinion is asked for and followed, whether cases are evaluated taking account of science and established experience and whether case verdicts are associated with legal certainty. Stratifying these questions by whether filed or not (Supplementary Table 1 - sheet Filed), the ‘cannot evaluate’ alternative has similar proportions in the group with 1–2 complaints filed, while in the two groups with 3 or more complaints the ‘cannot evaluate’ shares are lower. In the group with >5 complaints the respondents were critical (‘do not agree’ from 53 to 63%).

The most common response categories for whether the VDB’s positions positively influence the work-up of the patients I admit were ‘partial agreement’ (24.7%, middle category) and ‘does not agree’ (22.0%), and for whether this influence was negative ‘does not agree’ (33.6%) and ‘agree partially’ (21.5%, middle category) (Figure 3). The most common selected alternatives indicate that the VDB has the effects of more careful communication and more emphasis on record keeping (Figure 3). The most common alternative for whether VDB rulings would lead to changes in routines was ‘disagreement’ (32.3%). Most respondents answered ‘cannot evaluate’ to whether support or working time would be provided (39.9 and 43.7% respectively) if a complaint was filed to someone at their workplace. In total 66.7% of the 882 respondents stated they were acquainted with defensive medicine as a concept.

To the question whether you yourself would admit an animal owner that had previously submitted complaints 62.8% (95 CI; 59.5–66.0) answered no (n = 876), 23.1% (95 CI; 20.3–26.0) do not know and 14.1% (95 CI; 11.9–16.6) yes. The most common answer to whether the clinic would admit the same owner was do not know (39.1% [95% CI; 35.8–42.4]; n = 855), yes 33.9% [95% CI; 30–7-37.2]; and no 27.2% [95% CI 24.1–30.1]. Regarding whether clients should be admitted in four specific cases; a client having submitted a claim for simple mistakes, an unfortunate outcome, animal owner with problematic behaviour and animal owner spreading derogatory information it was most common to not agree (41.7, 37.3, 76.2 and 55.8%, respectively, Figure 4). These questions were analysed stratified by number of staff at the clinic, i.e., clinic size (Supplementary Table 1 - sheet ClinSize). Regarding the question concerning whether the respondent would admit an owner previously filing complaints the pattern was similar across categories relating to number of staff. Regarding whether the clinic would admit such animal owners, few clinics (10.1%) with 1–3 staff would admit such animal owners, while 45.8% of the respondents from clinics staffed by >8 stated that the clinic would admit such animal owners (Supplementary Table 1 - sheet ClinSize).

In total 524 respondents answered that they had had complaints filed, in 77.9% 1–2 complaints, 18.5% 3–5 and in 3.6% > 5 complaints. From this subset of 524 respondents, 507 answered the question about sanctions; 78.5% were acquitted, 19.1% had had 1–2 sanctioned complaints, 6 respondents 3–5 complaints (1.2%) and 6 respondents over 5 sanctioned complaints (1.2%; Table 2). Using all respondents as denominators, the proportion of men (62.6%) with complaints were larger than for women (47.4%). Even though numerators for those with 3 or more complaints sanctioned were small (n = 12), none of these were from female respondents (Supplementary Table 1 - sheet Gender). The proportions with complaints filed increased with years of experience, from 27.8% in those with <1 year of experience to 56.9% in those with >20 years of experience. Similarly, the proportions with sanctioned complaints also did so to some extent, from 0 to 14.4% in the groups with lowest and highest experience (Supplementary Table 1 - sheet Experience).

Regarding support from colleagues, only 25% of the respondents thought they got no support or only little support, adding the three first categories (Table 2). Similarly, most respondents (84.4%) disagreed over the statement that that they had been negatively treated by colleagues in conjunction with complaints filed. In conjunction with having complaints filed, 8.8% sought support from the Swedish Veterinary Association. Of these 45 respondents, 20 found ‘no value’ in the provided information. Of 520, 62 had sought legal assistance when having complaints filed. Regarding the question, whether a reason for the complaint filed was shortages at the workplace, that could be improved by introduction of operational oversight, 52.2% answered that they ‘did not agree at all’, while 10.1% ‘agreed fully’.

Figure 5 demonstrates that some respondents with previous complaints state that they put more emphasis on clinical records, that some avoid difficult animal owners, that some evaluate that only relevant assessments affect them and that their situation has not been affected by complaints filed to the VDB, with a large spread over most response categories for all these four questions. Regarding the other three questions (Figure 5), 46.1% of the respondents stated that they ‘do not agree at all’ with that they avoid veterinary care procedures as a consequence of having complaints filed to the VDB, and 73.3% stated they ‘do not agree at all’ with worrying about workplace economy and 44.0% ‘does not agree at all’ that they would worry about the reputation of the workplace on social media. The respondents with complaint filed answered whether they had had switched to part-time work (it was not asked whether receiving complaints contributed to the decision). This was selected by 132 out of 500 respondents (26.4, 95% CI; 22.6–30.5).

The most common answer to the question about the influence of inadequate communication was ‘very important’ (63.3%); to whether a complicated care process would lead to complaints- ‘somewhat important’/middle category (32.6%); to whether the animal dies despite a rather positive prognosis at outset ‘rather important’ to ‘very important’ (71.2% combining the three last categories) (Figure 6). Further, that the veterinarian investigates the wrong problem was somewhat less important, while that the animal owner thinks the veterinarian makes incorrect assessments or provides incorrect treatment was considered important with 46.7% answers pointing to ‘very important’. That the veterinarian does not suggests euthanasia in an animal owner-perceived bad condition was not suggested to be a very important reason (‘not at all important’ 34.5%), while the veterinarian suggesting euthanasia in an animal that the animal owner has not realised to be in a bad condition was considered rather important (74.6% combining the last three categories). Even of high care costs are not evaluated by the Swedish VDB, these were still considered important, 43.3% stating this was ‘very important’, while third party pressure was evenly answered over the five categories.

There were two questions about whether rules or guidelines could be overruled to some extent, to provide health care to animal owners who wanted for example cheaper alternatives, to which many agreed (Figure 7). Combining ‘partial agreement’ to ‘complete agreement’ (the four last categories), 75.8% agreed that this was the case, while for the practical example, whether dental treatment could be performed during sedation, respondents were more cautious with 25.0% directly disagreeing.

To the question whether other persons than the animal owner or the caretaker should be able to file complaints to the VDB, 63.6% (95 CI; 60.1–66.9) thought not, 18.5% (95 CI; 15.9–21.4) answered do not know and 17.9% (95% CI; 15.3–20-7) stated yes (n = 799). The responses (n = 783) to whether there should be a fee associated with filing a complaint were yes 56.6% (95 %CI; 53.0–60.1), no 26.2% (95% CI; 23.1–29.4) and do not know 17.2% (95% CI; 14.7–20.1). To the question whether you experienced, or heard others refer to, that complaints filed to the VDB have occurred in association with complaints filed to the County Administrative Board by the veterinarian due to inferior animal welfare; of 769 answers equal shares said no (50.2%) and yes (49.8%). Further, to the question whether you heard about cases of extorsion of a veterinarian, where the animal owner threatening to scandalise through social media or to file a complaint to the VDB, 61.5% (95% CI; 57.9–64.9) stated yes and 38.5% no (95% CI; 25.1–42.1). Figure 8 shows that most respondents thought they could not evaluate the composition and construction of the VDB (42%). Further many respondents agreed that an operational oversight would have positive effects on quality and access to veterinary care, 43.7% ‘agreed completely’. However, to the question whether an operational oversight would lead to fewer complaints to the VDB, the most common answer was ‘partial agreement’ (26.1%). To the question concerning whether an animal owner asks for a clinical record; would this in some cases cause hesitation or be denied, 76.7% (95% CI; 73.6–79.6) said no and 13.5% yes (95% CI; 11.2–16.1). The last question whether the respondent would recommend an animal owner, concerned about the costs of a certain case, to file an errand to the National Board for Consumer Disputes (27) 51.5% (95% CI; 48.0–55.1) said yes and 17.8% no (95% CI; 15.1–20.6). The last group 30.8% (95% CI; 27.5–34.1) were unaware that ARN could handle veterinary care costs complaints.

The targeted group was veterinarians in Sweden working clinically (28) or having worked clinically, around 2,800 veterinarians. The 1,000 veterinarians opening the link to the questionnaire suggests we reached more than one third of the target population (1,054/2,800). This is likely a larger share compared to many other studies on the same subject. Over 80% of the respondents were female, similar to the national gender distribution of veterinarians with 74% women (29). Over 67% of the respondents had more than 11 years of experience of clinical work. Taken together this implies that the study population to a large degree represents practitioners with large experience from the field. An overweight of females, mainly working in companion animal practice were found to be similar to respondent distributions from questionnaire samples addressing suicidal thoughts in the Norwegian veterinary population (30) or experiences of the Dutch VDB (3). Actually, very few complaints (0.4%) filed relates to production animals and 12% to horses (7).

Almost 50% of the respondents worked in smaller enterprises, a quarter owning or co-owning their practice. This share of owner or co-ownership was similar to that of the Norwegian veterinary population (30), but less than in the Dutch veterinary population (3). In our sample, 17% had more or less left clinical practice. However, few of these stated that the VDB or the regulatory organisation had a large impact on this decision. In the Dutch study (3) only 3% had left clinical practice.

In this discussion we do both national and international comparisons, guided by the idea that client complaints committees may be more optimal in some countries than other. However, there are more to what is best for a society, e.g., regarding between-country differences in the veterinary sector, than what is possible to evaluate here.

Using all answers (n = 1,054) producing conservative estimates given that not all answered the questionnaire in full, about half of the respondents (50%) had at least one complaint filed to the VDB. This result is considered representative considering that there were 2,816 clinically active veterinarians in Sweden per January 2025 (28) and a yearly average of 200 complaints being filed with the VDB (7). There may be a slight overrepresentation of veterinarians who received a sanction in this study (21%). This figure can be compared to a recent national average in Sweden regarding complaints filed, where 13% of complaints led to a sanction (7).

Regarding gender, more men (62.6% of all male respondents) than women (47.4%) had complaints filed against them. Part of this association is likely explained by male respondents having more years in the profession compared to female respondents. However, another study from Sweden showed that complaints filed to male veterinarians were associated with sanctions more often than those to female veterinarians, despite men being a minority in the profession (7). In addition, no female respondent reported receiving more than 1–2 sanctions, unlike men. When comparing shares of men and women in the veterinary population in New Zealand, men had more commonly received complaints compared to women (6).

Associations between demographic variables, e.g., experience and workplace, may have confounded overall results. For example, working in clinics owned by corporations was associated with having more complaints filed but also with being more experienced (Supplementary Table 1 - sheet ClinOwnVsExp). It is likely that more years of clinical work and patients admitted increases the likelihood of being reported. In the Netherlands 42% of veterinarians had faced a complaint to the VDB (3). A smaller study from the US (n = 92) showed that the rate of complaints to veterinary internists was higher (2). In total 64% had received one complaint during the previous 6 months and 93.5% stated they commonly receive a complaint to the VDB every few months (2). However, in our study, as in most other studies on the same topic, there was a risk of interest bias, as respondents with prior experience of complaints filed with the VBD may have been more, or perhaps less, inclined to complete the questionnaire.

Norwegian veterinarians reported on high emotional demands, negative work/life balance and fear of complaints (22). On a scale from 1 (no stress at all) to 5 (extreme stress) veterinarians answered with means from 2.0–3.1, indicating a moderate general stress level (22). We asked whether respondents enjoyed work, combining alternatives 1–3 on a scale of 7, only 10.2% in our study said they did not enjoy work and combining alternatives similarly 25.2% felt they did not have influence over questions of interest at their work. Naturally, respondents working in smaller business more often felt they had large influence (Supplementary Table 1 - sheet Workplace). In the 19 respondents that had had complaints filed >5 times, 10 did not enjoy their work, otherwise the pattern was similar across those with complaints filed and the overall population. We further asked whether respondents feared complaints by the VDB, of which 40% did, combining alternatives 5–7 on a scale of 7 in Figure 1. Earlier work has suggested veterinarians working clinically are indeed affected by VDBs, both when having complaints filed (2, 31) and more in general when deciding on treatment of patients during clinical work (9). Summarizing, our results suggest that complaints to the VDB indeed had an effect on a large minority of the respondents. However, respondents still enjoyed work, indicating that Swedish veterinary population may perhaps be less affected than the other populations studied.

All respondents were asked whether the workplace would provide support and time to address complaints, which many did not know. Stratifying the question by those with complaints filed and those without, the patterns were similar (Figure 3; Supplementary Table 1 - sheet Filed). Most respondents felt supported by colleagues, and few found themselves negatively received by other colleagues (Table 2). This is in accordance with veterinary internists from the USA (2), where 42% strongly agreed with feeling support from colleagues. Feeling support is likely important for coping with the stressful process of receiving a complaint.

Interestingly, regarding effects on the work situation in the population with complaints filed, most response categories, i.e., from no effect to large effect, were evenly selected (Figure 5). However, a third agreed completely with the statement that their situation is not affected at all. For three questions complaints seemed to have some impact: avoiding procedures, worrying about workplace economy, and worrying about the spread of information on social media. It can be concluded that the respondents with complaints filed, as a group, do not consider themselves heavily affected by complaints filed. Even so, 15% of respondents with complaints filed, Figure 5 fully agreed that they avoided similar tasks due to the complaint. This is in agreement with US veterinary internists (2), where 12% reported sometimes avoiding tasks (including both those with complaints and a few without). In a qualitative study, interviewing veterinarians with previous complaints (9), improvement of clinical records and avoiding tasks were addressed, and also avoiding animal owners perceived difficult to manage. We conclude that VDB rulings may sometimes affect the possibility for an animal owner to get help, perhaps in an urgent situation.

Comparing the answers in the total population to those with previous complaints filed (Supplementary Table 1 - sheet filed), it was the group with more than five complaints filed that disagreed with that expert opinion is used and followed, that the VDB rules according to science and established experience, and with that rulings are associated with high legal certainty. This suggests that veterinarians become increasingly critical the more complaints they get and perhaps the more they receive sanctions. In general, it is likely that persons driving long-standing issues with authorities become increasingly critical, while those without this experience will remain more neutral or positive.

US veterinary internist were asked to evaluate the statements, ‘Overall I believe complaints are reasonably dealt with’, and ‘Overall I believe the complaint process is handled competently’ (2). Most respondents (84 and 86% respectively, (2)) agreed or were neutral, while 65 to 84% (median across questions 74%) agreed of were neutral in our study (Figure 2). With lack of a ‘cannot evaluate’ option (2), comparisons to our results becomes complicated, but the comparison may perhaps suggest that the 92 veterinary internists regarded their VDB more highly. One area not addressed in the current study but cited as a stressing factor in other studies is the duration of processing complaints filed (9). In Sweden the process often takes about a year, a rather long time but this may be needed to achieve legal certainty and efficiency of the VDB (11), where group evaluation of complaints is conducted a few times each year.

Documents held by the VDB are, in general, public under the principle of public access to official documents in the Freedom of the Press Act (32). The identities of both reporting and reported persons are therefore normally public information (and therefore no information asked for in the questionnaire was considered sensitive). However, certain details may be subject to secrecy, for example if disclosure could be assumed to endanger the complainant or a related person (33). However, in the Netherlands there was an overweight for agreement that the VDB promotes best practice and more than half of the respondents also thought that practitioners can learn from the VDB rulings (3). Regarding the question to Swedish respondents thought on how they learn about, and perhaps learn from completed assessment, our study shows that it was only the respondents with frequent claims filed that also frequently ask the VDB for complete assessments (11 out of 19 Supplementary Table 1 - sheet filed). By contrast, 78% of the respondents read about the outcome of complaints in the Swedish Veterinary Journal and this share was similar for those with complaints (Supplementary Table 1 -sheet filed). This suggests that veterinarians are interested and have potential for both general improvement and updating, as well as self-preparation regarding possible complaints and the work of the VDB. Reading the complete information about cases has potential for increased knowledge of the process at the VDB compared to reading just extracts. Increased focus from practitioners on the process at the VDB, and to generally prepare for dealing with complaints, both practically and mentally (9) may be a way to make complaints handling less frustrating, perhaps extending to both basic and continuing education of veterinarians. Perhaps this could contribute to increased transparency of the work of the VDB.

In some contrast to gold standard care this study also explored perceptions on if care could be adapted for animal owners with smaller budgets (Figure 7) and asked about awareness of defensive medicine, known to raise human healthcare costs (19). Regarding a hypothetical question about if performing veterinary dentistry under sedation only, contrary to national and international recommendation that advocate general anaesthesia (34) should render a sanction from the VDB- veterinarians were of different opinions. Although dentistry is recommended to be performed under general anaesthesia (34), it is common to perform procedures under sedation only (35) which may be a more affordable alternative (20, 21), more recently addressed as contextualised care (22, 36).

Awareness of the concept of defensive medicine was high (67%) and consistent across gender and experience (Supplementary Table 1 - sheets Overall and Gender). Answers were ranging from ‘Agrees completely’ to ‘Do not agree at all’. Our findings indicate that many veterinarians are open to providing care that does not always follow the gold standard, depending on the context. This result is in line with the practice of spectrum of care medicine.

Many respondents agreed that the VDB leads to carefulness in communication with animal owners (52% combining the responses 5–7 on a scale of 7, Figure 3), and more emphasis on clinical records, but few agree that routines are changed after VDB assessments. The pattern for these questions was similar when stratified by years of experience. This is in line with research from California suggests that improved record keeping can be a deciding effect for avoiding sanctions by the VDB (5). This also agrees with a thematic study from the UK (9), where improved record keeping and carefulness in communication were addressed as consequences of having complaints filed to the VDB. US veterinary internists evaluated the statement ‘I feel the need to please my clients to avoid complaints against me’ and 63% strongly or partially agreed (2). In the current study, ineffective/poor communication was also an important perceived reason for complaints filed (Figure 6). Communication gaps have been addressed as a major point in many previous studies (1, 3, 6, 9). Professional behaviour is another common determinant of studies addressing reasons for complaints filed, also in veterinary medicine (e.g., (6, 9)). These factors highlight the importance of education and knowledge in so-called soft skills (7, 37) complementing medical skills.

As in the current study, high care costs (Figure 6) have also in other studies been addressed as cause of complaints (2, 6, 9), and health care costs have indeed increased (17, 38, 39). There is a risk that a high care cost contributes to many complaints filed, also when cost of care is not evaluated in itself. In Sweden, cases of perceived veterinary overcharging are currently addressed by the National Board for Consumer Disputes (27). ARN examines disputes between consumers and businesses, including veterinary fee disputes. ARN’s decisions are recommendations and not legally binding but are often complied with in practice. Proceedings are free of charge for the consumer and may be an alternative to filing a complaint with the VDB in cases concerning price or reimbursement. In this study, 52% of respondents would refer cost-related complaints to ARN; however, 31% were unaware of its role, indicating potential for improvement in directing dissatisfied animal owners to ARN instead of the VDB. Also, few of the respondents in our study thought that expanding the scope of the VDB to address overcharging was a good idea.

Most respondents would not like to admit animal owners that have filed complaints, or disrupted the work at the clinic, e.g., by being rude (40), or who have spread derogatory information on social media. Some answered that the clinic, but not themselves, may admit animal owners that made complaints previously. This was especially true for larger clinics (Supplementary Table 1 - sheet ClinSize). More possibilities for colleague support in larger clinics seems a plausible explanation for this finding. Overall, these findings suggest that some animal owners may risk having problems receiving care for their animal, if the veterinarians are aware of previously filed complaints. In Sweden there is no legislation that states that privately practicing veterinarians must admit owners. However, government-employed veterinarians, e.g., district veterinary officers (25) have a responsibility to provide care for animals 24–7 (41).

Around half of respondents had heard of VDB complaints that were preceded by reports of an animal owner to the County Administrative Board for inadequate animal husbandry. In Sweden such reactive filing was found in 4 of 47 euthanasia-related complaints (8). While the possibility that different forms of retribution may cause concerns among veterinarians, the extent is unclear, particularly in the era of social media where slander has become facilitated. Most US veterinary internists agreed with the statement that ‘there is no recourse against unfair online reviews’ (2). In the same study (2), over 50% reported knowing someone who had reimbursed an animal owner to avoid a complaint or negative post. Given the prolonged nature of complaint handling, perhaps especially in privately owned clinics such solutions may be seen as pragmatic. In the UK, mediation services (42) may after mediation with both parties suggest financial settlements between parties as part of complaint resolution. Summing up, it seems that reimbursements of animal owners when owners perceive that outcome and cost does not match are more openly promoted in some countries, e.g., in UK (42) or in Denmark (43) where the VDB can advise monetary reimbursement. In Sweden, ‘officially’ such reimbursement is done if advised by ARN (27) but could occur more ‘unofficially’ at some clinics to prevent, e.g., complaints to the VDB.

Over half of the respondents considered it a good idea to add a fee for the complainant when filing a complaint (strongly suggested by (3)), while few thought that additional persons other than currently (only animal owner, caretaker and the Administrative County Board) should be able to file complaints. Interestingly, for veterinarians to file complaints against themselves or colleagues is an option in, e.g., Norway (44) and it is also reported from the Netherlands (1, 45). Given that evaluations would be perceived as being associated with a high degree of legal certainty, filing a complaint against oneself may be an option for practitioners wanting to have a specific type of case tested or to simply file a complaint if the animal owner is concerned.

Regarding operational oversight, it is supported by the respondent population. In total 70% (response options 5–7 on a scale of 7, Figure 8) are generally positive to this introduction, while rather few think that it can alleviate the current level of complaints. Operational oversight may operate in two ways; complaints that after initial evaluation are found to relate to organizational matters could be directly forwarded. Operational oversight could also take the form of external auditing. External auditing can be combined with internal efforts. It is unknown to what degree in-house quality assurance processes are used, even if it is more likely that larger organisations (46), compared to single-veterinarian practices, put more emphasis on formal systematic quality control based on that they have more persons to coordinate.

A recent study describes that structures of medical disciplinary boards vary widely across the world (47). Also, VDB structures vary across countries (4). For example, Norway charges a fee to file complaints (44), unlike Sweden and the UK. The UK often resolves complaints through mediation (42) before reaching the VDB (48), a system not found in Norway or Sweden. Sweden (11) publicly discloses personal details from complaints (upon request), Norway anonymizes data online (40), and the UK names only the veterinarian and only if complaints reach disciplinary hearings (48). Public exposure in the UK is a source of stress (9). In recent years, Sweden handled over 200 complaints (49)—about three times more per capita than Norway (~30/year), and more than the UK’s ~ 20 published cases. Committees also differ: some issue sanctions or can revoke license, e.g., Sweden (12) and UK (50), others are advisory (44), or suggest sanctions or reimbursement (5, 43) or combinations thereof. While US vets report high complaint loads alongside general acceptance of the VDB’s role (2), it could be speculated that veterinarians can adapt to receiving many complaints. However, Swedish vets facing frequent complaints report significant stress, highlighting the need for support and transparency during the process (Figure 5). Our suggestion is that regulators should, when designing or redesigning VDBs as has recently been done in Sweden, inform themselves of functions and effects of disciplinary boards internationally.

There were some limitations in this exploratory cross-sectional study. The survey was anonymous and not systematically randomised. Therefore, we could not examine which segments of the veterinary population answered the questions. This may have created selection bias. Neither could we verify if an individual answered the questionnaire multiple times. We posed many questions and through the 95% CIs presented a large number of pairwise comparisons can be made. Surveys are inherently subject to biases, such as question/response wording bias, acquiescence bias, and recall bias (51). Non-response bias occurs when those who choose not to respond differ systematically from those who do—for example, individuals more dissatisfied with the VDB may have responded at a higher rate than those who are satisfied or indifferent. To minimize risk of drop-out due to this we included the response alternative ‘cannot evaluate’, which proved useful. It is however important to note that the majority of the studies we have compared our results to have similar issues with, e.g., non-response bias and recall bias. While comparing study results to results from other studies is key when discussing results, comparing between studies with unknown degrees of bias may yield biased conclusions. Although we aimed for international comparisons in this study, no collaborators were found abroad. The free-text answers warrant scrutiny and addressing, together with the quantitative material, but could because the presentation is already long not be included.

While VDBs are considered important parts in animal healthcare, in Sweden many veterinarians, but far from all, fear being reported. The high number of respondents indicate the importance of studying the effects of the VDB and being reported to the VDB. Many veterinarians are relatively unfamiliar with processes at the VDB and relatively few had received sanctions. Education in soft skills and preparedness for complaints may therefor add value. A large share of the respondents thought that not only gold standard care should be sufficient in certain circumstances, suggesting the VDB should have less emphasis on standard of care being “hospital oriented,” instead recognising and allowing the range of care of smaller clinics. To ensure legal certainty and predictability, and to minimize stress for those having had complaints filed against them, it is important that the processes are transparent, and evaluations are evidence-based, thus following science and proven experience.