In today's brave new world of information dissemination, you'd think our veterinary patients would benefit from the flood
of new and exciting medications and technologies the industry has to offer. But this is only partially true, as many of the
drugs, protocols and procedures we use need to be either pared back or nurtured—what really delivers, and what overpromises
Writing in the July 19, 2012, issue of the New England Journal of Medicine, author Jeffrey Avon, MD, professor of medicine at Harvard Medical School, points out in "Two Centuries of Assessing Drug
Risks" that some drugs and formulations can be dangerous. But how do we know which ones?
In the veterinary world, evidence-based medicine gets talked about a lot, but as Rod Bagley, DVM, head of clinics at Iowa
State University, says, we actually live in the realm of belief-based medicine, not evidence-based medicine. We operate under
the belief that this or that activity will help patients. Sitting in his office, he related stories to me from within his
neurology specialty where evidence is just plain lacking to support many of the clinical activities and common practices in
veterinary medicine today.
Certainly this conversation is a wake-up call to those of us on the front lines. It's also a message to academics, to people
who get all their veterinary medical information from the Internet, and to veterinary examining boards trying to establish
norms for the so-called "local standards of practice," which are used to pass judgment on veterinarians who must defend their
actions before these state boards.
Track outcomes to gather data
Veterinarians are presented with abundant opportunities to collect evidence. In a year, a veterinarian may see anywhere from
2,000 to 10,000 patients. There are all sorts of repeating cases: ear problems, lameness, skin infections, cruciate injuries,
cauda equina syndrome, seizures, abnormal lactate concentrations, fractures—and the list goes on. The literature, as Bagley
notes, offers a confusing constellation of solutions to similar issues. So, to change a "belief" into "evidence," you have
a simple tool at your disposal: green sheets. Unsure about something you're observing? Track your own data with green sheets.
To get started with the green sheet system, get bright-green lined paper and begin tracking issues on these sheets. Use one
sheet to track one issue, and log cases daily. If your practice is paperless, no problem—you can use Excel spreadsheets or
your practice software to track the same things. The issues we've studied in my practice are issues we've "green-sheeted."
For example, consider carprofen. This useful drug came into veterinary practices in the late 1990s to help with pain management.
Here's what we did in my practice: We took 100 patients, prescribed carprofen and tracked them. A few of our patients experienced
liver problems while receiving the medication, so we called the manufacturer to report this finding. The folks there advised
us that liver problems were not an issue with this product. Shortly thereafter, carprofen-associated liver problems hit the
front page of the Wall Street Journal. Now, when practitioners use carprofen, they monitor liver enzyme activities. Simple. It's the standard of care.
For ear infections, we compared two different ear medications and treatment plans. We assessed ear suction vs. a simple ear
cleaning. Try this: Treat 100 cases with ear suction and another 100 cases with ear cleaning and then compare the data. Is
one method clearly better? Our evidence points to suction working the best.