Coping with a hard-to-please client is a common stressor that’s part of the give-and-take in veterinary practice. But when a client conflict leads to a formal complaint to a medical board, the woe can take on exaggerated proportions.

Becoming the subject of a medical board complaint is unlike any other difficulty in a veterinarian's life. Crossing all geographic borders, veterinarians appear to have a universal reaction: deep and abiding stress.  

No wonder. While being the subject of a board complaint isn’t literally a matter of life or death, it may feel close to that, since a practitioner's license — his or her only legal means of earning a living as a veterinarian — is at risk. Moreover, resolution of a complaint can take anywhere from a few months to years.

The pervasive stress of a complaint recently led one veterinarian to ask colleagues via a message board of the Veterinary Information Network (VIN), an online community for the profession, how to survive the ordeal.

The veterinarian received many ideas about how to deal with it, along with thoughts on what it’s like. The experience was described as devastating, depressing, sleep-disrupting and expensive.

All boards have the same primary mandate — consumer protection. They also usually are responsible for licensure and continuing education. Many boards are comprised mostly of veterinarians, along with veterinary technicians and public members.

The initiation of an investigation isn’t complicated. Sue Geranen, executive officer of the California Veterinary Medical Board (CVMB), sums it up this way: “When a consumer believes something has been done incorrectly or negligently, they complain to the board, and the board investigates.” Despite procedural differences at each veterinary board in the world, the process is essentially the same in all jurisdictions.

As the board serving the most populous state in the United States — with a correspondingly high number of pet owners and veterinarians — the CVMB typically receives about 650 complaints a year. With 3,000 hospitals and 10,000 licensed veterinarians in the state, that amounts annually to about 22 complaints per 100 hospitals and 6.5 complaints per 100 veterinarians. (The ratio per veterinarian actually is slightly lower because typically a few complaints are directed at registered veterinary technicians rather than veterinary doctors.)

Few complaints result in license revocation or suspension. CVMB figures show that in fiscal year 2010-11, six practitioners lost their licenses, two were suspended with probation, and another four were given probation without suspension.
  
In the course of 30 years working with the board — 15 of those as executive officer — Geranen has found poor communication to be a chief source of complaints, whether it’s failure to explain cost of services, return calls or answer client questions thoroughly. Poor recordkeeping is another common issue.

Although most complaints do not lead to disciplinary action, “We don’t get a lot of frivolous complaints,” Geranen said. “We get some complaints where the complainants feel they were treated rudely or in a dismissive manner.” Those generally don’t go anywhere because the board doesn’t regulate manners, she said. But to help veterinarians avoid complaints in the first place, Geranen has a variety of suggestions for practitioners, key among them to thoroughly explain actions and procedures to clients.

Even fine doctors can elicit complaints, Geranen said, recalling an instance in which a veterinarian with a clean record drew five or six complaints in the space of two years. “Come to find out the person was a very good veterinarian but got so busy that they weren’t taking time to talk to the client,” she said. “The client saw it as negligence.

“The veterinarian’s like, ‘These are frivolous complaints.’ We said, ‘No, they’re not. You need to slow down, look the client in the eye, let them know, ‘I am examining this dog right now.’ Say, ‘I’m going to go out and send the tech in,’ not just rush out.”

Complaints made to the CVMB follow this procedure: A consulting veterinarian who does not know the subject of the complaint reviews the case. The reviewer decides whether the complaint is justified or should be dismissed. If the reviewer finds the complaint justified, another consultant (to whom the outcome of the first review is unknown) is asked to review the case. If both come to the same conclusion, the complaint moves forward. For relatively minor offenses, the penalty is a citation and fine in the range of $50 to $1,500. In the past seven years, the board issued citations and fines in an average of 71 cases.

Offenses that may net a citation include simple negligence or mistakes by a veterinarian with no prior record, Geranen said. A practitioner might, for instance, miss seeing something on an X-ray.

More serious complaints, following initial review by two consulting veterinarians, are referred to the state attorney general. That happened 40 times in 2010-11, out of 712 complaints filed, according to CVMB figures. Such cases typically involve suspicions of incompetence, fraud, deception and/or unprofessional conduct. Drug and alcohol abuse allegations also are considered among the most serious. A history of complaints and disciplinary action prompts closer scrutiny of a complaint, as well.

Geranen offered as examples these real-life cases sent to the attorney general:

• A veterinarian stepped out to the clinic lobby to look at a dog. The dog bit the veterinarian. The veterinarian kicked the dog in front of several waiting clients.

• A veterinarian accepted a dog for euthanasia, taking payment from the owners and having them sign a document authorizing the procedure. A few days later, a relative of the dog’s owners saw the dog running around the veterinary hospital. The relative informed the owners, who went to the hospital. By the time they arrived, the dog had been euthanized.

Complaint investigations take time. Even those that close with no further action generally require four to six months to resolve, Geranen said. Those referred to the attorney general usually take two to three years to complete. Veterinarians for whom disciplinary action is recommended, whether minor or major, may appeal their cases to an administrative law judge.

Compared with California, where the population is more than 37 million, far fewer complaints are lodged in a state such as Indiana, population 6.5 million. The number of complaints filed with the Indiana Veterinary Medical Board (IVMB) in 2010 was 38, amounting to 1.6 complaints per 100 veterinarians.

Dr. Richard Headley of Mishawaka, Ind., has been on the board for four years. He joined after an experience as the subject of a complaint. He’d been in practice for 36 years when a client alleged neglect that led to a dog’s death following surgery. The investigation dragged on for two years before the board dismissed the complaint. Headley found the lengthy experience grievously stressful. 

“During that long phase between the original contact and when you hear anything you begin to relax a little bit and you're kind of back to normal,” he said, “and then you get notified of the hearing and the whole thing starts all over.”

A few years after the dismissal, a colleague asked Headley if he was interested in joining the board. Headley agreed, not because of the complaint but because he’d always wondered how board investigations worked. As someone who has been the subject of a complaint and now considers complaints against others, he is in the unusual position of personally understanding both perspectives.

“I think most boards are made up of reasonable people doing a difficult job with the only reward being the knowledge that they are trying to do something to improve the profession,” Headley wrote in the VIN discussion.

The process for reviewing complaints is slightly different in Indiana from California. There, complaints are referred first to the attorney general. If the case is found to have merit, it’s returned to a board member who is assigned to receiving all complaints during his or her term. (That method ensures there will be enough members on the 8-person board who haven't seen the complaint before it comes to a hearing.) If the board member agrees that merit exists, the IVMB and attorney general’s office together decide how to approach the case.

Depending on the nature of the complaint, disciplinary action against a subject could be as simple as counseling, Headley said. Very few cases end up proceeding to a full board hearing.

Regardless of outcome, a formal complaint packs a significant emotional impact. It’s usually far greater than the financial one, judging from comments on the VIN message board. Even veterinarians who spend only a few hundred dollars to defend their position find themselves spending inordinate amounts of time and energy contemplating the case, second-guessing themselves, questioning their self-worth and agonizing over the potential ramifications.

Owner shot the cow, then complained 

Referring to herself as "Dr Stressed and Disheartened," Dr. Heather Shortridge of Armidale, Australia, experienced a formal complaint a scant 20 months into her career.  

The incident began with a visit to a hobby farm to check a pregnant cow due to calf. On that visit, she found the cow was not yet ready to deliver. In a subsequent visit the next day, Shortridge discovered that the fetus was dead. She performed a Caesarean to remove the calf. The situation went downhill from there.

"The owner shot the cow the following day, and wants to blame me that her cow is dead / is sad about the cow / really would like to destroy my career / does not wish to pay her bill," Shortridge summed up on the message board. "I’ve been stressed out by this process much more than I would have imagined. I’m sure I have damaged my teeth from all the grinding (I really need a mouthguard!), and I feel I have lost a fair bit of faith in humanity."

Shortridge explained in another VIN discussion that the complaint investigation centered on whether she should have determined sooner that the fetus had died. The complaint ultimately was dismissed in April, six months after it was lodged.

In an interview by e-mail with the VIN News Service, Shortridge estimated spending 20 hours doing research for her defense. That doesn’t count the time she spent ruminating over the incident. “Certainly it was my constant obsession from the moment I received the letter until the moment I received the dismissal!" she wrote. 

"I lost 5 kg (11 pounds) in about 2 weeks! I didn't buy a mouthguard but I definitely should have — the tooth grinding was epic," Shortridge said. "I think I just was generally more down for the entire 6 months. I ground my teeth on so many occasions and lost hours and hours of sleep. I cried a lot of times — including over things at work that I wouldn't usually cry over, and especially at our branch practice, which is where the complaint came from. I'm sure the staff at our branch practice maybe think I'm a bit nuts because when anything goes wrong there I fall to pieces a bit. I think I was probably quicker to be short with my colleagues, and also less friendly with the clients." 

The psychological toll far exceeded Shortridge's monetary expense. By joining Australia’s Veterinary Defence Association, she had no legal bills beyond a nominal membership fee. (The annual fee is $400, but because Shortridge joined part-way into the year, the charge was pro-rated.)  

Although the ordeal is behind her, Shortridge still thinks about it frequently. The experience moved her to draft an article she hopes to publish about the lingering emotional repercussions.

She wrote: "I have spent months feeling miserable. Perhaps not to the point of clinical depression but certainly to the point of it taking the joy out of many of my usual activities, and out of work, especially creating anxiety when I see new people or have to do something new with an owner present. ... I’m not sure exactly what it is about being sent to the board that makes it so devastating. But devastating is how I would describe it." 

Questioning one’s competence 

Veterinarians who reached out through the VIN message board to Shortridge during her time of angst included some who had been in the same frightening place. 

"I just got my first complaint dismissed a few months ago," commiserated Dr. Sophie Farrell of Seaforth, Ontario. "It was hugely stressful, and I did question my competence, and I did contemplate working at Wal-Mart. It also took 18 months, which for a baseless complaint is ridiculous, but I digress." 

Farrell is prohibited from sharing details of her case by confidentiality rules of the College of Veterinarians of Ontario. However, she was able to divulge the cost of her legal expenses — $1,100 — and discuss how the experience affected her.  

"I had a lot of trouble sleeping for a few nights when I got the initial complaint, and for a few nights again every time I got any mail related to it," she told the VIN News Service by e-mail. "Every time mail with the College logo on it was sitting in the mail box, I could feel this horrible adrenaline rush, my 'fight or flight' response kicked in and it took me a few days to 'come down' from that. 

“It was actually worse when the College mail didn't have anything to do with the complaint (i.e. when they sent my license renewal, newsletters, etc.) because then I knew that it still wasn't resolved. After a few weeks, I would finally manage to put it at the back of my mind, and then they'd mail me something else and everything would start over again.  The whole thing made me so incredibly angry and my poor husband got to hear about the whole thing.  His support was awesome, but I know that he doesn't like it when I'm that upset and he can't make it better, and it couldn't have been easy for him either. 

“I kept going over and over the case and wondering if I had made a mistake somewhere and that crossed over into a lot of other areas of my life as well. I guess I'm one of those stereotypical vets who have a huge part of ourselves tied up in what we do, so if that's attacked, your entire sense of self-worth takes a beating. The fact that to this day, I still can't see anything that I would have done differently (except hang up the phone and not see the case to begin with!) doesn't help the bruise to the ego." 

The price of ignorance

While neither Shortridge nor Farrell was found to be at fault, some cases, of course, turn out differently.

Dr. Fred Gingrich of Ashland, Ohio, knows what that feels like. Five years into his career, Gingrich was cited for inaccurate recordkeeping in violation of the state practice act.

The case began when one of Gingrich's cattle producer clients — his biggest client by far at the time, providing 10 to 15 percent of the clinic's income — was caught by the U.S. Department of Agriculture (USDA) selling unvaccinated heifers with fake brucellosis vaccine tattoos. The client used an old USDA stamp. 

The same client was simultaneously under investigation by the U.S. Food and Drug Administration (FDA) for meat-residue violations involving the painkilling drug flunixin meglumine. FDA rules prohibit slaughter of a food animal in fewer than four days after the animal has taken flunixin. Gingrich sold the medication to his client, but as is commonly done with livestock, the owner rather than the veterinarian administered the drug. Gingrich handled the client’s regulatory paperwork. 

"I didn't have a clue that any of this was going on," said Gingrich. At least, he didn’t until officers with badges showed up at his clinic. 

Within one week, Gingrich discovered he was being investigated by the USDA, the FDA and the Ohio Department of Agriculture (ODA). 

The client immediately told USDA investigators that Gingrich had no knowledge of the wrongdoing, although Gingrich didn't know that at the time. The client turned in the brucellosis shield and was fined $250.  

"I was cleared by the FDA," Gingrich said. "ODA was pissed that I did not know so they filed a complaint with the Ohio VMLB (Veterinary Medical Licensing Board) for 'records violations/failure to keep accurate records.' I cooperated. But the thing that caused most of my stress was the Ohio VMLB hires out investigators and guess who they hire? ODA!  So the guy that submitted the complaint came to my office to investigate the complaint. I then hired an attorney and refused to talk to them."  

His attorney is a veterinarian and lawyer. Gingrich felt that background was critical to the attorney’s handling of the complaint.
 
Gingrich’s stress level already was high before the incident because of financial concerns. “The thing I was most concerned with was, we had bought a practice and this was our second or third year of operation,” Gingrich said. “We were heavily mortgaged and busy. It was two guys running a three-man practice. If I'd lost my license we would have been sunk financially, period. I was mostly concerned about the financial aspect of the practice mortgage, not that I could have lost my license.” 

A few months later, the OVMLB decided it would prosecute Gingrich unless he accepted a no-contest plea (with no admission of guilt) and a $1,500 fine plus the cost of investigation.  

"I refused but my attorney suggested I take the plea because financially he cost more than the fine,” Gingrich said. “I agreed and paid them. My total cost for attorney fees and fine was about $10,000. Countless hours and lost sleep."

Complainant was a happy client

Sometimes, complaints spring from the most seemingly benign occurrences. That was the experience of Dr. Marco Veenis of Kelowna, British Columbia.

The incident started when a client brought in a dog for a spay. Following the operation, the client commented how much better this dog looked compared with a dog she’d had spayed previously. Veenis explained that anesthetic and surgical protocols had improved and that he typically removes only the ovaries —  an ovariectomy, or OE — rather than removing both ovaries and uterus — ovariohysterectomy, or OVH.

"Three months later I got the dreaded letter from the VMA demanding my records, as the client filed a complaint," Veenis recounted by e-mail to the VIN News Service. "It turned out that her stepfather was an ex-president of the Veterinary Medical Association (VMA), 10 years retired. When she mentioned to him that I only removed the ovaries he immediately recommended she file a complaint, as leaving the uterus in could cause all kinds of problems and was not ‘how it was done.' " 

Veenis was accused of misleading his client by asking consent for a spay and not removing the uterus, thereby endangering his patient. The complaint officer told Veenis she felt his actions were such a serious infraction that she would proceed even if the client dropped the complaint. 

Veenis argued that OE is a valid, well-published and less-invasive alternative to OVH. He provided 17 references from dictionaries stating that "spay" was defined as the removal of the ovaries — not the uterus — of a female animal. The complaint officer eventually told Veenis that she had researched the issue and the complaint would not be pursued. 

Veenis then filed a complaint against the retired ex-president for practicing without a license and violating bylaws. After meeting with the man later, Veenis dropped the complaint because the man admitted he had not seen a textbook in a decade and apologized.  

But that wasn’t the end of the battle. Veenis received a letter from the Conduct Review Committee expressing concern over his "confrontational nature" and stating that it concluded that a “spay” is defined as an OVH, not an OE.

Although the committee did not cite Veenis, the letter stated that the committee wanted other veterinarians to be aware of the issue, so it planned to ask the ex-president to write an article for the board’s magazine. Fearing that the ex-president would frame the newer surgery in a poor light, Veenis asked if he could write the article. The committee agreed on condition it be allowed to review the article before publication.

Veenis thought the piece would be a feature article, but it was published in the “Disciplinary Files” section without his byline. He asked for a rectification plus authorship in a peer-reviewed publication (the board’s magazine is not peer-reviewed). Nine months after he made repeated requests and threatened a defamation lawsuit, a one-line rectification was printed in an obscure part of the publication.

Years later, the episode still troubles Veenis.

"My only crime was that I used a surgical technique the complaint officer was not familiar with and that she and others did not bother to research before roasting me,” he said. “The VMA has never offered any kind of an apology." 

Long-term changes result 

Whether a veterinarian is found at fault, many subjects of complaints say they come away from the experience with a strong tendency to practice defensive medicine. 

"It made me darn sure I write everything down," said Headley. "It cost my clients a lot of money and it continues to cost them today — there's nothing like a charge like that to throw you into defensive-medicine mode. I continue to advise and insist upon lab studies whereas before I would have let them slide. I now take extra precautions that for years I didn't think were necessary." 

Complaint survivors make changes that are positive, as well. Headley noted that one veterinarian found at fault by the IVMB made a "huge improvement in his practice, including records, which we check quarterly."

Shortridge takes better notes than she used to. "I do think it has helped my histories ... and generally made me hyper-aware of dotting 'i's and crossing 't's," she said. 

Gingrich found that his work was easier without that one huge client. "Whatever I made on him wasn't worth it. And I learned this lesson: no client is worth it. It used to be this big client ran the show. I run my own show now. If the producer doesn't like my work I don't do it. I hold myself to a higher standard," he said. 

The approach seems to work. Gingrich’s practice has since expanded, and he now owns two clinics — one for large animals, one for small.

As for Farrell, "I am no longer afraid to say 'no," she said. "Ultimately, the only reason that I saw the case (that led to the complaint) at all was that I made the classic new-grad mistake of allowing myself to be bullied into doing something I wasn't comfortable doing (in this case, seeing a species I wasn't comfortable with). I was so scared to say ‘No, I'm not comfortable with this’ that I let someone 'make' me see the case and it came back to bite me. I have since said 'no' to my boss, and guess what? It was okay!  I don't ever want to have to deal with another board complaint, and if this is what needed to happen to make me grow a pair, I suppose it may have been worth it." 

After dealing with a complaint, some veterinarians who did not have license-defense insurance obtain it. Otherwise, the cost of defense can run the gamut. Gingrich's legal fees were around $10,000; Headley's about $6,000; and Veenis’s about $4,000. 

"Any vet that does not have license-defense insurance is being penny-wise and pound foolish," Headley declared.

Edie Lau contributed to this report.

This report was revised from the original to correct the name of the regulatory body that investigated Dr. Sophie Farrell's case.