Before prescribing, do you weigh the risks and benefits?

Oct 01, 2008

In your opinion, which of the following questions is most commonly asked about management of disorders that affect our patients: 1) How do you treat the problem? or 2) How do you diagnose the problem?

In my experience, it is the first question.

I have spoken often with veterinarians who are too busy to pursue diagnostic evaluations of their patients. I have uncommonly encountered those who say they are too busy to treat their patients.

Who cares? you might ask.

The point is that we have not placed enough thought and emphasis on the well-established fact that drugs and surgical procedures may be harmful as well as helpful. Too often the justification for empirical therapy is the firm belief that some treatment is better than nothing at all.

There has been misplaced emphasis on what drug to prescribe rather than whether to prescribe.

In the past, criticism of seemingly logical therapeutic interventions that resulted in an unfavorable or even fatal outcome was rare, as long as there was faith that some good might have been achieved.

How often have we heard, "Will you have to do surgery, Doctor?"

What is the response if the patient dies?

"Well, at least we tried."

In my opinion, blind acceptance of such logic is an example of intellectual Browian Movement.

We live in a world of "pharmacomania" and have done so for centuries. We are all part of this problem.

Modern medicine men now appear several times per hour on television, in magazines, in newspapers, in medical journals and on the Internet to tell us about tired blood, erectile dysfunction, insomnia, gastric hyperacidity, urinary incontinence and constipation, and to champion the availability of pills to cure these ills based on evidence generated at "leading medical centers" and "doctors like yours."

This type of promotion contributes to public misconceptions about the value and need for drugs, and reinforces values, attitudes and behaviors that encourage drug use.

Many health-care providers have responded by demonstrating their belief that most diseases and disorders can be resolved or helped by drugs or surgery.

Acceptance of the value of various therapeutic modalities is unconsciously reinforced by the fact that most diseases we encounter are self-limiting. In fact, the severity of most disease declines within a day or two. In this scenario, any form of treatment may appear to be beneficial as long as it is not overtly harmful.

We should remember that the fact our patient got well does not prove that our diagnosis was correct, or that our treatment was effective.

Hippocrates is remembered primarily for his admonition, "First, do no harm."

That infers that therapeutic intervention will be based on reliable scientific knowledge and rationale (so-called "evidence-based" medicine).

But, is the widespread administration of antibiotics to attempt to cure patients with non-infectious disease based on scientific knowledge? Is the daily consumption of phenomenal doses of vitamins by individuals already consuming an overabundance of food logical? Is the administration of glucocorticoids to patients with immune-mediated diseases caused by immunosuppression rational?

The answers to these questions are obvious, and yet such actions continue to be commonplace.

The psychological pressure imposed on veterinarians to do something in terms of caring for ill patients occasionally is overwhelming.

But our desire to do something must be evaluated in light of potential risks and benefits of the therapeutic action we are considering.

Let me rephrase a well-known cliché: Don't just do something — stand there!

On occasion the psychological benefits of some form of treatment may justify the risks, but these should carefully be considered by all concerned. Informed consent is essential.

Ask yourself: "If I or a member of my family faced a serious illness, would I have confidence in the care of a physician with intellectual and technical competence comparable to mine?"

Ultimately the decision to do something should be guided by the principle that we are committed to the well-being of our patients first — and last.

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.