A very common complaint of owners/bosses to new grads are that they ‘don’t know real world medicine’. New grads graduate with their minds filled with Gold Standard medicine. They go into clinics and are immediately bombarded and blocked by performing Gold Standard medicine with comments such as ‘oh that’s not what happens in the real world’, or ‘I always do this and it works’, or ‘that’s great for school, but this is how it is really done.’ Conferences and veterinary groups have also recently been criticizing veterinary schools for not including this Real World medicine into their curriculums.
GOLD STANDARD:
DEFINITION: Gold Standard is thought of as ‘do every test possible’. It is interpreted as completely working up every single case, getting a definitive answer to every possible scenario, or at least as close as an answer as possible, and treating every single case as completely as we possibly can.
PROS: Patients get the best possible care, and we heal as many patients as possible.
CONS: In veterinary medicine the care we are able to provide is limited to clients financial and emotional limitations, therefore often Gold Standard cannot be pursued.
REAL WORLD:
DEFINITION: Real World is practicing based on what has previously been done, previously worked, and personal experiences based on what is most likely. Mainly trained by Pattern Recognition.
PROS: Helpful in circumstances when finances are limited, disease processes are very common, simple or easily diagnosed, or when the animal will get better despite any treatment.
CONS: Unhelpful in circumstances where disease process is complicated or rare, definitive treatment is required for recovery, or when clients are keen to get a definitive answer. Also unhelpful at progressing the medical profession.
Pattern Recognition, when properly trained can be a very useful and important tool in medicine, and is accurate 80% of the time- WHEN ACCURATELY TRAINED.
In veterinary medicine, because we very rarely get a definitive diagnosis, our pattern recognition is often inaccurately trained, leading to mistakes!
IMPORTANT NOTE:
Pattern recognition in medicine is the process of seeing a case, and assuming that we know the answer without testing based on our previous experiences with similar cases. In veterinary medicine, since we often don’t get a definitive answer, the training of our pattern recognition is flawed in that we will assume that a case responding to our treatment was a- correctly diagnosed, and b- correctly treated. However, since most of our patients will get better without us intervening at all, a large percent of the time our pattern recognition is incorrectly trained. Pattern recognition training only accurately works on cases where we can get clear, unequivocal, answers. This is uncommon with the diversity of cases that we see.
Is is very important to note that pattern recognition is VERY important in medicine, especially emergency, and is comprised of about 80% of the correct diagnoses that you will make, however we need to think critically about how we train our pattern recognition, and how we implement it into future cases.
KICK ASS VETS recommends always striving to perform EVIDENCE BASED MEDICINE (EBM). By focusing on practicing EBM we eliminate the discussion about Real World or Gold Standard and we focus on providing the most up-to-date, yet still practical medicine possible in every circumstance.
EVIDENCE BASED MEDICINE:
DEFINITION: Medicine based on evidence from properly designed and conducted research and studies. It tries to eliminate, as much as possible, anecdotal medicine. It also implies keeping up to date with the most recent and newest findings, as science and medicine are constantly evolving fields. It is the combination of performing the best possible medicine, while taking the financial and emotional components of the case into account. It is the marriage of Gold Standard and Real World, combining up to date and research backed medicine with the needed practicality of clinical practice.
What does Evidence Based Medicine Mean for Clinical Practice?
EBM in clinical practice means that you don’t prescribe medications without first thinking ‘What am I treating?’, ‘Is this medication indicated?’, ‘Are there any reasons to NOT use this medication?’ And ‘Is the use of this medication scientifically supported in this situation?’
When you are pursuing interventions or diagnostics, EBM means that you use tests and treatments that have been scientifically shown to work, and you do diagnostics that have been proven to be accurate, sensitive and specific enough to rationally warrant use. You decrease the ‘waste’ of resources on tests that are not actually giving you any more information that don’t change your treatment plan, and you decrease the risk of relying on ineffective tests and missing other important information.
By focusing on performing EBM, you will decrease or eliminate the emotional decisions we make. Ex. when we use antibiotics out of FEAR from a client complaining.
EBM also eliminates/decreases the treatment of patients with medications or interventions that are not actually helping the patient and may be causing harm. Ex. steroids given to head trauma or spinal injury patients.
Most importantly however, EBM progresses the profession forward, and does not allow outdated medicine/information to perpetuate for years and years. Veterinary medicine is SO SLOW to progress, and so slow for new research to ‘hit the shelves’ of veterinary practices. EBM will speed the process.
IMPORTANT NOTE:
Evidence Based Medicine first relies on knowing WHAT is available, and HOW it can be used. It relies on knowing the FULL EXTENT of what can, and medically should, be done in regards to every case. This is the definition of Gold Standard. This means that EBM has its foundations built solidly upon Gold Standard, and the trick (or 'practice' of medicine) is picking and choosing what parts of Gold Standard apply to each case and situation, while always ensuring every decision is scientifically supported. Without the knowledge of ‘Gold Standard’, EBM falls apart.
What Should be Taught in Vet Schools?:
Currently, in vet schools, Gold Standard is being taught. It is the ideal, and it is the ‘best practice’. KICK ASS VETS feels this is the best and most appropriate approach, and that schools should continue to teach Gold Standard for the following reasons:
1. CLIENTS WANT IT: There is a huge amount of evidence to show that the human-animal bond is growing stronger and stronger all the time. 65%-90% of pet owners describe their pet as part of their family. Sometimes pets are described as more important than close family members including that of spouse, children, parents or siblings. We know that animals today are loved as humans, and many individuals and couples are pursuing ‘fur-babies’ in lieu of having human babies. People are more concerned than ever to get the very best care for their pets, and a significant percentage of the pet-owning population that are happy and willing to pay whatever it costs to get it.
The human-animal bond is growing stronger all the time, and is displayed in how we dress up our fur-babies. Clients WANT extensive care, and it is our job to offer and provide the best care possible.
2. GOLD STANDARD IS THE FOUNDATION: As described above, EBM is the best and most practical approach to performing veterinary medicine in today’s society so that we are progressing the profession, pursuing the best possible medical care, all while taking into account individual circumstances. EBM CANNOT be performed, and cannot exist, without the foundation that it is built upon. Gold Standard knowledge is required to be able to tailor EBM to each individual case, and required to be able to not fall into the ‘trap’ of anecdotal medicine.
3. LEGALLY REQUIRED: As veterinarians we have an ethical and legal responsibility to offer our patients options, and to inform clients of the choices they have. If we don’t know what is available, and how to best work up case, we cannot offer it. ‘Gold Standard’ should be offered to every patient, so that clients know their options. This is not only legally important to cover your butt, but it is important for clients to be given options that they may wish to pursue.
4. PROGRESS THE PROFESSION: In order to push medicine forward and to keep the flow of information from researchers to clinical practitioners moving, we need to infuse new and updated medicine into the profession. This occurs to a small extent through CPD/CE, but to much larger extent it occurs through new graduates entering the veterinary profession and performing the most up-to-date medicine. If new grads were not taught ‘Gold Standard’, this information would take even longer to get to clinics.
So, at KICK ASS VETS we believe that ‘Gold Standard’ SHOULD be taught in schools, so that all new graduates know the latest medicine, know what is available, know how it can be implemented and are able to bring that to their clinics. This is not only a good thing, but is IMPERATIVE to progress our profession! We, as a profession, NEED Gold Standard to be taught, and encouraged, and pushed. We NEED the new grads coming into the clinics saying ‘Hey, actually we do it this way now’. New grads also NEED the knowledge of Gold Standard to be able to make EBM clinical decisions, to educate clients on why they are doing things differently and gain the clients respect and acceptance of their approach.
Clinic owners and experienced vets need to do their part as well! We all need to be open to the latest Gold Standard medicine, and be keen to learn, and continue to practice EBM. We need to not push Real World (anecdotal) medicine on new grads, we need to allow them to practice the way they were taught, and teach us a new trick or two! The best clinics are where experience and education meet and work harmoniously!
Almost all veterinary schools have classes where client communication is taught. In these classes the concepts of offering multiple levels of patient care for various budgets and desires should be discussed. Communication on how to pursue EBM while still fitting into a clients budgets or with limited resources should be taught.
KICK ASS VETS feels that teaching Real World or anecdotal medicine is detrimental to the profession. Veterinary schools NEED to DISCOURAGE the use of outdated practices because unless we have someone pushing advancement, we will all slide back down. Clinical practice will put so much pressure on vets to perform inappropriate medicine, so we need that background from school to keep us on track. Ex: How can vet schools express and communicate the IMPORTANCE and NEED of appropriate antimicrobial use if they are at the same time saying ‘sometimes it is ok to use antibiotics willy nilly’.
We NEED the universities to be doing their best to teach the importance of updated medicine! In fact, the WORLD needs schools to be encouraging best practice, and discouraging anything that is less.
As veterinarians we have a responsibility to the world to practice evidence based medicine. Our clinical decisions impact the world, and we have the power to make a positive change.
Summary:
KICK ASS VETS should be striving to perform Evidence Based Medicine for every case. Veterinary Schools should be teaching Gold Standard as this is the best way to progress the profession. Having discussions about using EBM in clinical practice is important, and needed in classes as well, however the importance of Gold Standard should not lose focus. Veterinary schools are responsible for not only preparing veterinarians for work, but are more importantly responsible for teaching the profession as it should be practiced! Veterinary schools are where the profession progresses, and we should NOT diminish this so that ‘experienced’ veterinarians can continue to practice outdated medicine without having to adapt and grow, or for clients to demand medications or interventions with no knowledge.
Resources
To perform EBM it is helpful to have textbooks and resources so that you can base medical decisions on updated knowledge, instead of relying on your boss/mentor, especially as a new graduate.
