15 years of facts and figures on veterinary disciplinary measures in the Netherlands

In most countries, a veterinary disciplinary system is in force to ensure the quality of the veterinary profession and to offer an objective platform for complaints. We present an analysis of 15 years of veterinary disciplinary verdicts (2001–2016) to compare facts and figures and identify which factors are of major influence on the outcome of the verdicts. Rulings were collected from both paper files and the digital database of the veterinary disciplinary council (VDC), categorized, and used to create a database that enabled a statistical analysis. The results showed that complaints pertaining to companion animals are filed predominantly by owners, whereas complaints about livestock are mostly filed by the governmental civil servant (CS). CS complaints mostly address compliance issues. For the complaints made by owners (client complaints, CCs), reporting, communication, and veterinary mistakes appeared to be of statistical significance. Further studies are needed to investigate the impact of the complaints on veterinarians in general and how we can improve the veterinary disciplinary system.


Introduction
In most countries, like the Netherlands, a veterinary disciplinary system is in force to ensure the quality of the veterinary profession and to offer an objective platform for complaints. When first established in the Netherlands, its primary goal was animal welfare and food safety (1) but from the start, it served as a platform for client complaints (CCs) (2). Owners may perceive a veterinary disciplinary system as a body that they can use to file their complaints but it is actually a system to ensure quality and improve veterinary care (3,4). Owners rarely realize the effect of their complaints. CCs have a huge impact on veterinarians and their co-workers (4)(5)(6). Recent studies investigating the effect of complaints in both human and veterinarian medicine have shown that complaints contribute to psychological distress such as depression, burnout, anxiety, and even suicidal ideation (7, 8), and health problems such as cardiovascular disease, .
/fvets. . insomnia, headaches, anger, and relationship problems (5,9). Although the possibility of complaining may stimulate health workers to improve their level of care, the detrimental effect on job satisfaction and mental health (4-6) may warrant a critical analysis of these disciplinary systems as well. The Dutch veterinary disciplinary system was first established in 1990. In contrast to the disciplinary system of, for example, the UK (10) or the USA (4), where complaints are first evaluated by a committee and only taken into consideration after careful scrutinizing, nearly all complaints sent to the Dutch veterinary disciplinary council (VDC) are taken into consideration. The original intent of the Dutch government, when establishing the VDC, had been the importance of veterinary care for livestock as it is one of the most important agricultural economic activities in Dutch (11). For this reason, the legal system was not designed to separate complaints in different ways. Regardless of the nature of the complaint, veterinarians feel forced to respond. This may have, like in other countries, a huge impact on their well-being (4-6).   Although VDC and VAC are in function for over 29 years, a scientific analysis of the nature of the complaints and the rulings of the VDC and VAC has not yet been performed. This study aimed to describe the sources of complaints, the reasons for the complaints, and the kind of rulings made.

Materials and methods
For the analysis in this study, we chose the VDC rulings from the years 2001-2016. Rulings prior to this date were either incomplete or not available for this analysis and hence had to be excluded. At the time of analysis of this study, most of the rulings beyond this time frame were, for various reasons, not yet available to us and will therefore be analyzed in a different study.
This study was neither subjected to ethical approval as it does not involve any use or experimental use of animals nor will any data be disclosed that are subject to any privacy laws.
The rulings were systematically arranged in an inventory data set. The data were collected both from paper files and the digital database of the VDC. Only the data of complaints handled by the VDC and VAC are included in this Excel database. Complaints that have not been handled, or resolved for various reasons, such as administrative errors, have not been registered and are therefore unknown to us.
All rulings contained data that were used to establish different value labels which could be categorized into excel rows. Different value labels were created such as animal species, size, gender, age, type of complaint, outcome, etc. A complete list of these different value labels and their descriptions are found in Table 1. The value labels were coded into subcategories to enable further analysis. A complete list of these value labels and subcategories is listed in Appendices I and II.
The complete data set consisted of rulings of the VDC and VAC. The data sets were first checked for errors and missing values, and when possible, assigned a numeric property and imported into SPSS. All rulings, whether from the VDC or VAC, used the same value labels. The VDC rulings were grouped into six categories: (1) the complaint is either dismissed or inadmissible for instance due to administrative reasons, (2) unfound, (3) found with either no measure or a warning or reprimand, (4) a fine conditional or unconditional, (5) Microsoft Excel .

SPSS version for statistical analyses.
Frontiers in Veterinary Science frontiersin.org . /fvets. . a fine and/or (un)conditional suspension, and (6) partial or complete removal of the veterinary profession. The VAC data are measured in equal, heavier, or lower rulings, and an additional parameter was the person who appealed to the ruling of the VDC, such as either the CS, veterinary, or the owner. The veterinary disciplinary council data set was first analyzed using all rulings. First, the effect of time on the outcome was studied: found or unfound, and second, whether there was a time effect for the ruling itself. We used Kendall's tau association test because the rulings were non-parametric ordinal data.
As the complaints filed by the CS address mostly legal issues and hence are of a completely different nature compared to those filed by owners, the CS and CC rulings were analyzed separately. Each subcategory (Appendices I and II) was analyzed for the two types of rulings: CS and CC rulings. To see whether there was a statistically significant effect for each subcategory for either "found" or "unfound, " a Fisher Exact test with a pvalue for the significance of <0.05 was used. The CS rulings were analyzed for (1) animal species, (2) status (deceased or not), (3) influence of reporting, and (4) the summary of the complaint. If the information was missing (for instance whether the animal had died or not), that ruling was excluded from the analysis.
The CC rulings were analyzed for (1) animal species, (2) sex, (3) age, (4) status (deceased or not), (5) influence of reporting, (6) dog breed, and (7) summary of the complaint. If the information was missing (for instance age or breed), that ruling was excluded from the analysis.
The veterinary disciplinary appeal council rulings were analyzed for (1) the person who appealed, (2) the type of appeal, and (3) the influence of reporting with as a dependent parameter the new ruling, using a Fisher Exact test with a pvalue for significance <0.05. If applicable, a two-tailed Pearson correlation coefficient was calculated.

Descriptive analysis rulings VDC
A total of 1,197 verdicts were available for analysis. The number of complaints involving companion animals was 890 (74%) out of 1,197 verdicts; 157 (13%) complaints concerned equines, and 150 (13%) were related to livestock. In total, 1,023 complaints were filed by owners (CCs) (85%) representing a vast majority in contrast with the 174 cases filed by the CS (15%). The total number of cases did not vary greatly during this period. The mean number was 79 cases per year with a range of 68 to 92 Frontiers in Veterinary Science frontiersin.org . /fvets. . ( Figure 1). During the analyzed period, the number of CS cases gradually increased and the number of CC cases decreased. In both groups, the number of inadmissible cases declined during the analyzed period (Figures 2, 3). Cases filed by the CS addressed more than 96% of compliance cases (Table 2). During the analyzed period, the number of CS cases gradually increased. During the period from 2008 to 2011, more rulings were made with (un)conditional fines and suspension (Figure 2). After this period, most rulings concerned fines (Figure 2), and this difference was statistically significant (p < 0.001). A similar statistically significant effect was observed for the year, irrespective of whether the ruling was found or unfound (p = 0.011). Cases filed in the period after 2008 were more likely to be found. The majority of CS cases concerned livestock (79%), 8% concerned companion animals, and 13% concerned equines (Table 2). There was no statistically significant difference for animal species, status, or influence of reporting, irrespective of whether the ruling was unfound or found (Table 2). However, there was a clear statistically significant difference if the summary of the case addressed compliance issues (p = 0.01).
The number of CCs gradually decreased as mentioned above ( Figure 3 and Table 4). This was partly due to the decline in inadmissible cases. There was a clear effect for year and ruling (p < 0.001). In the first analyzed period, the number of cases that were considered to be unfound decreased, whereas the number of cases that were considered to be found remained constant ( Table 3). The CC cases were analyzed for several categories, irrespective of whether they were judged to be found or not. Animal species, sex, age, status (deceased or not), or dog breed had no statistically significant effect on the outcome of the ruling (Table 4). However, there was a clear statistically significant effect for reporting and the summary of the complaint (mistakes and communication) (Table 4). Poor reporting resulted more likely in a "found" ruling (p < 0.001). The statistically significant effect was even greater for communication and veterinary mistakes (p < 0.001).

Descriptive analysis rulings veterinary appeal council
A total of 177 appeals were submitted during the analyzed period (Table 5). In the majority of these cases, the VAC came to a similar verdict as the VDC (70%). In 18% of the cases, the verdict was lower compared to the VDC and higher in the remaining 12%. Owners, veterinarians, and the CS could appeal, where owners appealed in 53% of the cases and .
/fvets. .  veterinarians appealed in 42%. The variables appellant, type of appeal complaint, and influence of reporting proved to be of statistically significant influence (Table 5).

Discussion
This study is an analysis of 15 years of rulings made by the VDC and VAC. The goal of these rulings is 2-folds: to improve veterinary care and to serve as an objective platform for complaints (2, 3). However, the majority of cases concerned CCs from companion animal owners. Only around 12% of the cases concerned livestock animals, and the majority of the cases were filed by the CS. These CS cases mostly addressed compliance issues and if the veterinarians did not fulfill their duty of care, they are at great risk of being fined, or temporally suspended as a veterinarian. Based on the outcome of the CS cases, we concluded that if it concerns compliance issues, the system works. However, as the number of cases only increased during this period, either the CS became more active in controlling or a learning effect is absent. Although it was not the intent of the Dutch government to create a platform, especially for CCs (2), the vast majority of cases concerned CCs. CCs have a huge effect on the well-being of veterinarians and co-workers (4-6), .
/fvets. .  Although it should be possible to complain as it may also improve our level of care (6), the detrimental effect on job satisfaction and mental health (4, 5) justified a critical analysis of the rulings.
Looking at the performed analysis, there are, in light of the effect of a CC, some recommendations. In principle, every CC is taken into consideration by the VDC. The legal system does not provide an option to treat complaints of a less heavy character, and/or rooted in the owner's frustration, through a different complaint route. The "unfound" ruling can only be made after a full disciplinary procedure, which plays a major role in the veterinarian's well-being and job satisfaction (4-6). It seems safe to conclude that the current method of working could be adapted.
This study has limitations. The actual impact of a CC on the veterinarian could not be studied. It is not possible to establish the exact amount of learning effect. It would have been very interesting to compare the outcome of this study with different veterinary disciplinary systems in other countries. There is, one recent Californian study providing insights from the veterinary disciplinary system, but this study addresses different issues (4). But all of these questions will be subject to additional studies.

Conclusion
It is concluded that compliance, performing its duty of care, proper record keeping, good communication, and avoiding veterinary mistakes can reduce the number of CS complaints and CCs. Additional studies are needed to investigate the impact and learning effect of CCs on veterinarians.

Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
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