Applying 6 time-honored axioms to treatment - DVM
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Applying 6 time-honored axioms to treatment


DVM360 MAGAZINE


A documented example of inappropriate treatment is empirical use of antimicrobics to treat sterile (no aerobic bacteria isolated) lower urinary-tract inflammation commonly encountered in cats. Some justify anti-bacterial therapy in such patients because, while receiving antimicrobics, the associated clinical signs often subside within a week. These colleagues apparently overlook the fact that clinical signs in untreated cats with the same disorder typically subside in less than a week. I am reminded of the proverb, "God heals the patient and the Doctor takes the fee."

This scenario underscores the next clinical axiom:

Just because two events occur in consecutive order does not prove a cause-and-effect relationship (Axiom #2).

Even though most veterinarians are aware of this axiom in context of feline idiopathic lower urinary-tract disorders, many still continue to use antimicrobics for such patients. (See evidence in a related article in JAVMA, volume 214, No. 10, May 15, 1999: pages 1470-1480.)

Some have not yet learned that clinical impressions are inherently unreliable, generally conforming to our preconceived biases. They apparently ignore the fact that belief or unbelief does not alter the truth. Repetition does not transform errors into facts. If hundreds of authorities unknowingly make incorrect statements, they are still incorrect statements. There is a huge conceptual difference between unanswered questions and unquestioned answers. The lesson I have learned is that, at times, making a diagnosis merely marks the point at which we have suspended diagnostic investigation.

Won't you agree that our clinical diagnoses often are a matter of opinion rather than a matter of fact? It is one thing to make a diagnosis and another to substantiate it.

In fact, "just because a favorable outcome occurs in association with our treatment does not prove that our diagnosis was correct, or that our treatment was effective (Axiom #3).

Unrelated coincidences (aka, confounding factors) commonly are associated with the treatment and subsequent clinical course of numerous diseases.

Since many, if not most, diseases that we encounter are self-limiting, we must use appropriate caution in interpreting uncontrolled empirical observations about the efficacy of our therapy.

We should not ignore data just because it does not coincide with our beliefs. Rather than interpreting facts in light of preconceived conclusions, we must be alert to allow reproducible observations (facts) to lead us to reasonable conclusions. Why? Because the severity of many disorders often declines in a day or two. In this situation any treatment may appear to be beneficial as long as it is not harmful. I am again reminded of the proverb that God heals the patient, and the Doctor takes the fee.

How does 'first do no harm' encompass inappropriate therapy?

When confronted with situations in which therapeutic options are associated with substantial risk to our patients, we must avoid the mindset of, "Don't just stand there, do something!" Why? Because, although the psychological pressure imposed on veterinarians to do something can be overwhelming, our desire to do something right must be evaluated in light of the potential benefits and risks to the patient.

There are times when it is in the patient's best interest to, "Don't just do something, stand there!"

We must not misplace emphasis on what treatment to prescribe when the fundamental question is whether to prescribe (Axiom #4).

Too often, justification for unproved treatment is the belief that some treatment is better than nothing at all. However, the prognosis of few diseases is so uniformly poor that any form of treatment can be justified.

Prognosis of diseases requires judgment in the absence of certainty (Axiom #5).

Therefore, when making prognoses, we must remember that "almost right" is still wrong. For some patients, prognoses encompassing evidence-based recommendations are life-saving; for others, they are a death sentence.

When possible, the choice of any type of therapy should encompass knowledge of the patients' previous history of intolerance to drugs (rash, tremors, anorexia, vomiting, diarrhea, etc.). Also, to minimize adverse drug reactions, it is best to avoid unnecessary use of multiple combinations of drugs. To enhance compliance, the owner should be asked to participate in formulating the frequency and route of administration of the drug (See "Minimizing medication mistakes: a checklist for clients," DVM Newsmagazine, Volume 35 #8, page 1s, 2004).


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