What would you think if you walked into a gun club and observed someone taking target practice with a pistol? Would you look for some sort of target? What if you did not see a target, but instead the individual seemed to be shooting at random?
Would you ask the person about the general direction of his bullets? What would you think if the reply was, "whatever the bullet hits?"
Would you have confidence in this person's thought process?
On the other hand, what would you think if the person identified a clearly defined target with several bullet holes in the bulls-eye?
Now place yourself in this scenario:
If your colleagues walked into your treatment room, would they find you using shotgun therapy based on a ready-fire-aim approach? Would they find you relying heavily on cortico steroids and antibiotics as your silver bullets? Or would they find clearly defined targets based on correct observations and interpretations of thoughtfully planned and implemented diagnostics?
Some might defend a lack of thoughtful planning as practical. To be sure, when properly used, practicality is a virtue. But in my experience, for one to say, "that's not practical" often is simply an excuse to justify ignorance. In some situations, the concept of practicality appears to represent inaccuracy of aim rather than insufficiency of endeavor.
Therapeutic target practice
Are your therapeutic plans designed to hit a well-defined therapeutic target?
In this essay, we make the case that goals of treatment we provide to our patients are somewhat analogous to target practice.
- First, practice makes better.
- Second, for professional reasons (encompassing ethical, moral and financial reasons), we should have clearly defined therapeutic targets that are derived from evidence-based medicine for each of our patients. Consider the following:
Do you recall Hippocrates' admonition?
He said, "As to disease, make a habit of two things: help, or at least do no harm." (Axiom #1).
It follows that we should do our best to describe the treatment we are recommending and the evidence-based rationale for it. Why? Because goal- setting fosters precision, and precision enhances quality patient care. Won't you agree that no patient should be worse for having seen the doctor?
What are the potential goals?
Conceptually, all types of treatment can be categorized as one or a combination of five possible types:
SPECIFIC TREATMENT is given to eliminate, destroy or modify the primary cause(s) of the disease process. Examples of specific treatment include use of antibiotics for bacterial infections, antidotes to counteract toxins and replacement hormone therapy.
SUPPORTIVE TREATMENT consists of therapy that modifies or eliminates abnormalities that occur secondary to primary disease. Treatment designed to correct deficits and excesses in fluid, electrolyte, acid-base, endocrine (e.g., recombinant erythro-poietin to stimulate red cell production in renal-failure patients with non-regenerative anemia) and nutrient imbalance (modified diets) caused by primary renal failure is an example of supportive therapy. Successful specific therapy often is dependent on successful supportive therapy.
SYMPTOMATIC TREATMENT consists of therapy given to eliminate or suppress clinical signs. Examples of symptomatic treatment include use of anti-emetics to control vomiting and use of glucocorticoids to control pruritis.
PALLIATIVE TREATMENT consists of therapy chosen to suppress the clinical signs of patients with diseases for which the underlying cause cannot be cured and is likely to persist or is likely to be progressive (e.g., chronic progressive azotemic renal failure).
INAPPROPRIATE THERAPY consists of therapy that is not needed by the patient, is contraindicated for the patient or therapy for which the associated risks outweigh the probable benefits.