I've been trying to see if I could get a 5 star vet clinic and found a general lack of consistency in my ability to get even a single 5 star review. From doing some debugging, what I found is that after "greeting warmly" all the buffs related to points I would have earned before that interaction (from environment and from social interactions) were gone.
I poked around with various graphics settings and found that removing vsync helped a bit, but generally I could still only get maybe 2-3 5 star ratings at most per attempt. I also notice better chances with getting 5 stars when it's the first time I've played for the day and if I restart the game (unless I had already played for a while). I mention this because I feel there's a chance it may be related to graphics or memory contributing to some kind of race condition, but I can't really confirm and no graphics setting fully fixed the issue.
Because of this I feel people on some hardware might not experience this (or not as often), but in doing research I've not been able to find anyone in more recent years being able to achieve 5 stars, and the general sentiment seems to be that getting a 5 star vet is extremely difficult (hence the reason I started testing and from what I found I think issues with the game are making this feat impossible on my system through normal gameplay).
Other conditions where I could get 5 star ratings is when one of the vets I hired "steal" a patient from me or at times when they take up a patient on their own. However, relying on npc vets to get higher scores is also very inconsistent.
Without the environment score, and the buff you are supposed to receive for "greeting warmly", the remaining options for getting the points required to get to 5 stars is limited, especially as the only buff you have regular access to for getting points in the bedside manner category is the friendly pet social as the friendly owner social "Banter about Pet" becomes unavailable after greeting the owner unless you circumvent the social restrictions by showing the patient photos. If you do circumvent it and are able to access this interaction (which is a hassle without a mod to search interactions) this will also get rid of all other scoring buffs earned before this point.
As far as mod usage goes, I was primarily using MCCC to track the hidden buffs to see what was going on with my scoring and the Smarter Pie Menu mod to have a better ability to search interactions. Other script mods include Kuttoe's Home regions and two small ones including an auto-thermostat mod and one to readjust calories and add a small passive burn. I did test without mods and other than no longer being able to track what was happening with the buffs, found no improvement in my ability to earn a 5 star vet clinic.
With mods, what I saw was that my vet clinic was getting the "beautifully decorated" scoring buff for max points in the aesthetics category until I greeted the patient. I was never able to see the buff related to greeting the patient warmly and did see the buff for bantering about pet go away as soon as I greeted the patient as well.
If I cheated back in the relevant buffs I was able to get 5 stars. I was also able to get 5 stars consistently with a small mod I made to rev-evaluate the aesthetics upon the loot_OwnableVetClinic_WaitTime_Stop action and that gave the only social interaction without issues (Call a Good Pet) max scoring in the business_vet tuning. Something like this could be a workaround for the short-term if whatever is causing the buffs to disappear upon certain social interactions is unable to be fixed.
