The Art of Private Veterinary Practice L’art de la pratique vétérinaire privée The double gold standards Myrna Milani
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ne of the many changes experienced by practitioners, thanks to the Internet, is increased access to more scientific studies and articles than in the past. Even though Dr. McCutcheon may complain when her clients surf the web in an attempt to diagnose their animals’ conditions and find the best treatment for these, as a new graduate she takes full advantage of the research and academic databases to which she has access. She likes the additional confidence knowledge of relevant studies gives her when she discusses their animals’ problems and treatments with some of her more demanding and critical clients. Meanwhile Dr. Ramos, her employer with several decades of practice experience, admits that while he does try to keep current on the latest research, he devotes less time to this than in the past. “But why?” protests his younger colleague. “Scientific data is the gold standard of our profession.” “It’s not that I don’t think it’s important. I do,” replies Dr. Ramos. “But not as all-important as I did when I was a new graduate. Besides, some of the study conclusions and the treatments and protocols based on them that were presented as the gold standard when I was a student and young practitioner are considered unacceptable today.” When he notices her incredulous look he adds, “For example, the use of antibiotics to ‘treat’ bacterial problems or to promote weight gain, over-vaccination, confidently assuring clients that there were no negative effects associated with spay and neuter for their companion animals. Then there’s this.” Dr. Ramos turns his laptop toward the younger practitioner so she can see the article he was reading when she entered their shared office. Her eyes widen when she reads the title: “It Ain’t Necessarily So: Why Much of the Medical Literature is Wrong” by Christopher Labos, MD CM, MSc, FRCPC (http://www.medscape.com/viewarticle/829866). When her colleague gets called out to treat an animal experiencing an emergency, she reads the article. In it the author notes that when people read that a statistical association exists between X and Y,
Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. CVJ / VOL 56 / FEBRUARY 2015
many automatically assume that this means X causes Y. However the author then goes on to explain that there are 5 other situations that also could explain those same results. i) Reverse causality. When a statistical association between X and Y exists, it is equally possible that Y causes X as X causes Y. Sometimes this point is not always made clear when results and conclusions are discussed. ii) Random chance. Whenever an association exists between two variables, the possibility exists that this is the result of mere coincidence. iii) Bias. Bias occurs when the way the study is conducted creates an association between X and Y that is not actually present. iv) Confounding. Confounding occurs when a third factor that is not taken into account in the study influences the association between the two variables. v) Exaggerated risk. This causes Dr. McCutcheon to recall a statement made by the instructor of her statistics course to illustrate the power of statistical analyses: “Numbers don’t lie, but statisticians sure can.” The intent was to remind students that the same numbers may yield different results depending on the kind of statistical analyses the researcher applies to them. Because several years had passed since she took the course, the veterinarian welcomes Dr. Labos’s clear and concise definitions and examples of these phenomena. At first she tries to convince herself that the article is not relevant to veterinary medicine because it was written for physicians and referred to human medical studies. But she soon dismisses this possibility because she remembers enough of her statistics course to know that these same problems could occur in any field, including veterinary medicine. Then she turns her attention to what she considers even more important to her at that moment: what this information means to her as a practitioner. An hour later when Dr. Ramos returns, she hands him his laptop and admits how much she has depended on her ability to cite and if possible implement the latest research to establish her credibility with her new clients. “Am I really undermining my credibility instead?” she asks. “I don’t think so, if for no reason than most experienced clients as well as human medical patients expect this kind of 199
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behavior from new grads,” her employer assures her with a smile. “But the more you get to know your clients and patients, the more information you can add to your research-based database and what you learned in your clinical rotations in school.” “True,” she agrees. “But I can see why you devote less time to reading journals than I do.” “I still make every attempt to keep current,” he reminds her. “But relative to practice, I see research as reflecting a gold standard that may or may not be all that relevant to a particular client and patient. Relative to my interaction with clients, I’m now focusing more on developing my skills as a client- and patient-centered practitioner because more clients expect me to have these too. That’s why I found that article so disquieting.” When his associate’s puzzled look indicates that this connection is not as clear to her as it apparently is to him, he clarifies his statement. “I used to complain a lot — and still sometimes do — about clients who go to the Internet first for answers regarding their animals’ illness or injuries. And when I thought of them doing this in the past, I always thought of them reading articles or blogs written by those with what I considered substandard credentials,” he explains. “But increasingly some of my clients are just as likely to have access to scholarly search engines at work or at home, and they may be reading scientific studies with conclusions they consider the gold standard too. “At the same time though, they rightfully believe that their animals and their animals’ particular medical problems, and how those problems and any treatments play out in their environments are unique. They don’t want their animals to be reduced to a ‘kennel cough,’ ‘cystitis,’ ‘mastitis,’ or ‘laminitis.’ So the challenge is to be able to communicate with them in a way that maintains the balance between the more detached and sometimes arcane knowledge of science and the more specific related to a singular animal, client, and environment.” Dr. Ramos then goes on to describe what happened when he aborted his barely begun lunch break to meet with his emergency client, Ms. Neimark, a retired pediatric nurse. Ms. Neimark’s 19-year-old cat has multiple medical problems, the treatment of which has required the veterinarian to con-
200
stantly balance the sometimes complex needs of his patient and client. Prior to retiring to her parents’ old home in Dr. Ramos’s more rural area, Ms. Niemark worked in a large teaching facility where she was surrounded with cutting-edge medical technology on a daily basis. Additionally she routinely interacted with those who regularly discussed the latest medical literature and often implemented innovative and experimental procedures and treatments on their critically ill patients. During this time she also had access to and used multiple medical databases, and she still kept in touch with her former colleagues. All this Dr. Ramos learned from the community grapevine to which Ms. Niemark’s numerous local relatives had been frequent contributors. When Dr. Ramos first met with Ms. Neimark, she also made it clear to the veterinarian that her cat was her baby. That combined with the cat’s large folders of hardcopy and electronic medical data his new client had forwarded to him caused Dr. Ramos to assume she intended to drive the 150 miles to the nearest veterinary specialty hospital for anything but the most routine care for her animal. But as it turned out, he was wrong. The cat hated to ride in the car and Ms. Niemark was far more interested in establishing what she considered a quality relationship with a practitioner who knew her and her cat well enough to make their final years together as comfortable as possible. “I did the medical best then,” said his client that first day as she gestured toward the cat’s bulging file that detailed diagnostics and complex treatments well beyond the capacity of the veterinarian, his staff, and facility, “and I intend to do my best now. But now my standard of best is different.” Admittedly life would be simpler if only one standard of excellence existed for veterinary practitioners and all clients and patients agreed on it. But frustrated though practitioners may be when they get blindsided by a scientific study with questionable conclusions, or by a client more interested in the veterinarian’s ability to listen and communicate than do the latest diagnostic test or dispense the newest drug, for most practitioners the feeling passes. And when it does, it leaves behind the satisfaction that comes from knowing that the best standard is inevitably the one that ensures the highest quality clinician-client communication.
CVJ / VOL 56 / FEBRUARY 2015
O
ne of the many changes experienced by practitioners, thanks to the Internet, is increased access to more scientific studies and articles than in the past. Even though Dr. McCutcheon may complain when her clients surf the web in an attempt to diagnose their animals’ conditions and find the best treatment for these, as a new graduate she takes full advantage of the research and academic databases to which she has access. She likes the additional confidence knowledge of relevant studies gives her when she discusses their animals’ problems and treatments with some of her more demanding and critical clients. Meanwhile Dr. Ramos, her employer with several decades of practice experience, admits that while he does try to keep current on the latest research, he devotes less time to this than in the past. “But why?” protests his younger colleague. “Scientific data is the gold standard of our profession.” “It’s not that I don’t think it’s important. I do,” replies Dr. Ramos. “But not as all-important as I did when I was a new graduate. Besides, some of the study conclusions and the treatments and protocols based on them that were presented as the gold standard when I was a student and young practitioner are considered unacceptable today.” When he notices her incredulous look he adds, “For example, the use of antibiotics to ‘treat’ bacterial problems or to promote weight gain, over-vaccination, confidently assuring clients that there were no negative effects associated with spay and neuter for their companion animals. Then there’s this.” Dr. Ramos turns his laptop toward the younger practitioner so she can see the article he was reading when she entered their shared office. Her eyes widen when she reads the title: “It Ain’t Necessarily So: Why Much of the Medical Literature is Wrong” by Christopher Labos, MD CM, MSc, FRCPC (http://www.medscape.com/viewarticle/829866). When her colleague gets called out to treat an animal experiencing an emergency, she reads the article. In it the author notes that when people read that a statistical association exists between X and Y,
Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. CVJ / VOL 56 / FEBRUARY 2015
many automatically assume that this means X causes Y. However the author then goes on to explain that there are 5 other situations that also could explain those same results. i) Reverse causality. When a statistical association between X and Y exists, it is equally possible that Y causes X as X causes Y. Sometimes this point is not always made clear when results and conclusions are discussed. ii) Random chance. Whenever an association exists between two variables, the possibility exists that this is the result of mere coincidence. iii) Bias. Bias occurs when the way the study is conducted creates an association between X and Y that is not actually present. iv) Confounding. Confounding occurs when a third factor that is not taken into account in the study influences the association between the two variables. v) Exaggerated risk. This causes Dr. McCutcheon to recall a statement made by the instructor of her statistics course to illustrate the power of statistical analyses: “Numbers don’t lie, but statisticians sure can.” The intent was to remind students that the same numbers may yield different results depending on the kind of statistical analyses the researcher applies to them. Because several years had passed since she took the course, the veterinarian welcomes Dr. Labos’s clear and concise definitions and examples of these phenomena. At first she tries to convince herself that the article is not relevant to veterinary medicine because it was written for physicians and referred to human medical studies. But she soon dismisses this possibility because she remembers enough of her statistics course to know that these same problems could occur in any field, including veterinary medicine. Then she turns her attention to what she considers even more important to her at that moment: what this information means to her as a practitioner. An hour later when Dr. Ramos returns, she hands him his laptop and admits how much she has depended on her ability to cite and if possible implement the latest research to establish her credibility with her new clients. “Am I really undermining my credibility instead?” she asks. “I don’t think so, if for no reason than most experienced clients as well as human medical patients expect this kind of 199
L’A R T D E L A P R AT I Q U E V É T É R I N A I R E P R I V É E
behavior from new grads,” her employer assures her with a smile. “But the more you get to know your clients and patients, the more information you can add to your research-based database and what you learned in your clinical rotations in school.” “True,” she agrees. “But I can see why you devote less time to reading journals than I do.” “I still make every attempt to keep current,” he reminds her. “But relative to practice, I see research as reflecting a gold standard that may or may not be all that relevant to a particular client and patient. Relative to my interaction with clients, I’m now focusing more on developing my skills as a client- and patient-centered practitioner because more clients expect me to have these too. That’s why I found that article so disquieting.” When his associate’s puzzled look indicates that this connection is not as clear to her as it apparently is to him, he clarifies his statement. “I used to complain a lot — and still sometimes do — about clients who go to the Internet first for answers regarding their animals’ illness or injuries. And when I thought of them doing this in the past, I always thought of them reading articles or blogs written by those with what I considered substandard credentials,” he explains. “But increasingly some of my clients are just as likely to have access to scholarly search engines at work or at home, and they may be reading scientific studies with conclusions they consider the gold standard too. “At the same time though, they rightfully believe that their animals and their animals’ particular medical problems, and how those problems and any treatments play out in their environments are unique. They don’t want their animals to be reduced to a ‘kennel cough,’ ‘cystitis,’ ‘mastitis,’ or ‘laminitis.’ So the challenge is to be able to communicate with them in a way that maintains the balance between the more detached and sometimes arcane knowledge of science and the more specific related to a singular animal, client, and environment.” Dr. Ramos then goes on to describe what happened when he aborted his barely begun lunch break to meet with his emergency client, Ms. Neimark, a retired pediatric nurse. Ms. Neimark’s 19-year-old cat has multiple medical problems, the treatment of which has required the veterinarian to con-
200
stantly balance the sometimes complex needs of his patient and client. Prior to retiring to her parents’ old home in Dr. Ramos’s more rural area, Ms. Niemark worked in a large teaching facility where she was surrounded with cutting-edge medical technology on a daily basis. Additionally she routinely interacted with those who regularly discussed the latest medical literature and often implemented innovative and experimental procedures and treatments on their critically ill patients. During this time she also had access to and used multiple medical databases, and she still kept in touch with her former colleagues. All this Dr. Ramos learned from the community grapevine to which Ms. Niemark’s numerous local relatives had been frequent contributors. When Dr. Ramos first met with Ms. Neimark, she also made it clear to the veterinarian that her cat was her baby. That combined with the cat’s large folders of hardcopy and electronic medical data his new client had forwarded to him caused Dr. Ramos to assume she intended to drive the 150 miles to the nearest veterinary specialty hospital for anything but the most routine care for her animal. But as it turned out, he was wrong. The cat hated to ride in the car and Ms. Niemark was far more interested in establishing what she considered a quality relationship with a practitioner who knew her and her cat well enough to make their final years together as comfortable as possible. “I did the medical best then,” said his client that first day as she gestured toward the cat’s bulging file that detailed diagnostics and complex treatments well beyond the capacity of the veterinarian, his staff, and facility, “and I intend to do my best now. But now my standard of best is different.” Admittedly life would be simpler if only one standard of excellence existed for veterinary practitioners and all clients and patients agreed on it. But frustrated though practitioners may be when they get blindsided by a scientific study with questionable conclusions, or by a client more interested in the veterinarian’s ability to listen and communicate than do the latest diagnostic test or dispense the newest drug, for most practitioners the feeling passes. And when it does, it leaves behind the satisfaction that comes from knowing that the best standard is inevitably the one that ensures the highest quality clinician-client communication.
CVJ / VOL 56 / FEBRUARY 2015
