Applying 6 time-honored axioms to treatment

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?

Therapeutic Axioms

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.

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).

Keeping our eye on the target

Once the goal of therapy is defined, the feasibility of such therapy must be assessed. In many situations, the final choice will represent a balance between the optimum therapy for the problem(s), the availability of optimum therapy and the type of therapy our clients can or are willing to afford.

There must be no misunderstanding about what is wanted and what is given. In a symbolic way, we must determine whether our clients want "a dog, a horse, a cow, a cat, etc.," or "this dog, this horse, this cow, this cat, etc.," while at the same time being our patient's advocate.

Life is too precious for us to allow ourselves to become hardened about the welfare of patients that cannot speak for themselves.

How important are medical axioms? The bottom line is encompassed in this one:

"There are some patients we cannot help; there are none that we cannot harm (Axiom #6)."

Carl A. Osborne DVM, PhD, Dipl. ACVIM 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.