Abstract
Clinical veterinary medicine is demanding. General practice calls for a broad array of knowledge and abilities. The world is an uncertain and shifting place at best.
In the light of these statements, it is prudent to look closely at our clinical practice. Four questions seem germane:
What do we know?
How do we know it?
What do we do?
Why do we do it?
As Donald Schon has written, reflection is the mark of the accomplished professional. 1
Clinical questions abound. One of those concerns the best means to manage hypertrophic cardiomyopathy (HCM) in cats. In this issue, Drs Rishniw and Pion report on a survey of board-certified veterinary cardiologists and other veterinarians with an expressed interest in, or focus on, veterinary cardiology, looking at therapeutic decisions in a dozen scenarios. 2 They address a fascinating question and conclude that there is a ‘marked disconnect between published clinical data for therapy of cats with HCM and treatment choices made by cardiologists and non-cardiologists when treating both clinical and subclinical HCM.’ They further recognize that those surveyed ‘often prescribe treatments knowing [emphasis added] that little documented evidence supports their decisions.’ These conclusions should spur practitioners to consider how an evidence-based medicine philosophy might be applied to daily clinical work.
Evidence-based medicine (EBM) was defined in an early text on the topic as the conscientious, implicit, applied effort to bring the use of the current best evidence and the clinician's experience to bear in the treatment of individual patients. 3 Five steps have been identified in this process: 1) identify a need for information and build a good question; 2) find the best evidence; 3) appraise the validity, impact and applicability of the evidence; 4) integrate appraisal, experience and patient needs; and 5) evaluate efficacy and efficiency in carrying out steps 1–4 and seek ways to improve them. 4
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Clinical questions abound. Answers may not be so plentiful, but the process of finding and then applying them — evidence-based medicine — provides a sound basis for daily veterinary practice
The four questions posed in the second paragraph fit well into the evidence-based scheme. The seemingly simple ‘what do we know?’ raises many questions and challenges. What in the ‘current best evidence’ is reliable now, what is it built on, and will it be the same in the years ahead? Are there things worth knowing based simply on experience? Within the EBM framework, there are guidelines for searching and validating the literature that relate to the question ‘how do we know it?’ Dense literature searches and deep validation may seem to be daunting tasks for the busy practitioner and, indeed, often the highest levels of evidence are not available to us, the work simply not having been done. Even so, the EBM framework is not in itself complex and provides a sound basis for daily practice. If the practitioner does nothing more than bring steps 1 and 5, the easiest parts, fully to daily practice, that practice should still be enhanced. Admittedly, steps 2 and 3 are more difficult to do, but easier with today's technology than they used to be.
Socrates famously said that the unexamined life is not worth living. Asking the questions ‘what do we do?’ and ‘why do we do it?’ can provide great insight into the whole idea of EBM. The first of these questions is the easier to answer and is equivalent to what in EBM terminology would be called a background question. It is the answer to the second, considering how the published literature and our training and experience have influenced our behaviors, that opens the door to thoughtful reflection. It is enlightening to look carefully at any treatment you do or diagnostic test you order in this way and to ask what it is in the literature and/or your experience that has led to this. The door to EBM practice is then open.
EBM is a philosophy. As with any philosophy, questions and difficulties will confront its adherents and practitioners. In 2000, more than a decade ago, Dr Bruce Keene, a veterinary cardiologist at North Carolina State University, addressed the issue of the direction of EBM in an editorial in the Journal of Veterinary Internal Medicine. 5 Today resources are more plentiful (there is, for example, a professional association dedicated to evidence-based veterinary medicine, www.ebvma.org) and it is possible for general practitioners to benefit from the structure that EBM provides. 6,7 Drs Rishniw and Pion have offered ample intellectual stimulation to lead the inquisitive clinician to further consideration of EBM as a useful tool in general practice.