Veterinary medicine takes many cues from human medicine – diagnostic tools, information about bones and tissue behavior, new drugs. According to one renowned internal medicine specialist and author, there's something else veterinarians should take away from their counterparts in human medicine: a warning.
Dr. Abraham Verghese, vice chairman for the theory and practice of medicine at Stanford's School of Medicine, was the keynote speaker at the recent annual convention for the American Association of Equine Practitioners. Verghese has become known for his writings and lectures (including a Ted Talk) on the importance of bedside medicine. His basic thesis is that in human medicine, the patient on the computer screen gets more attention than the patient in the bed, as doctors become overwhelmed with the volume of data provided by new technology.
Verghese pointed to a study from 2012 in which a researcher submitted himself to daily medical testing for 14 months. During that time, blood markers and genetic testing revealed two infections and a change in blood glucose levels which signaled very early diabetes.
While the disease anticipation was good, the project generated enough 153 million data points – enough to fill 838 miles of bookshelves.
“As much data continues coming down the pike, let's not kid ourselves,” said Verghese. “We just wrote a paper titled 'What this computer needs is a physician.' Artificial intelligence is going to change our world. I don't know if it's going to change your world, but it might.”
As much as technological advances are helping clinicians, they're also posing problems. One study found the average emergency room doctor makes 4,000 mouse clicks in the course of one shift to enter records, order tests, and process results from tests into a typical hospital computer record-keeping system. Just sending someone to the cath lab for chest pain took 140-odd clicks. For every hour spent with patients, doctors are believed to spend two hours working on medical records, which extends to longer days as they spend off-time trying to catch up.
It's little wonder the burnout rate for primary care physicians is estimated at 50 percent. Veterinary burnout is similarly high, with only 24 percent of vets under the age of 34 recommending the profession to others, according to a study from 2015.
Equine veterinarians may not be dealing with millions of data points on each patient, but many of them are faced with increasing time pressures that make it easy to skimp on the physical examination.
Dr. Jeffrey Berk, newly-elected president of the AAEP, recruited Verghese to be the keynote speaker at the convention because he sees certain parallels between human and equine medicine.
Berk believes veterinarians, like most people these days, are on information overload. For many, the overload can be traced back to graduate school. Veterinary students are required to learn the anatomy and physiology of all species and aren't permitted to specialize in one or two species until later in the program.
The real problem, though, is that the pace doesn't slow down when they graduate and open a practice. People are busier than ever, and veterinarians are no exception. Berk pointed to the lame horse as an example.
“The ideal approach is to do a thorough physical examination to determine in which limb or limbs the horse is lame, and then diagnostic nerve blocking to localize the lameness. This can be time consuming if done properly,” he said. “To circumvent this process and just take radiographs up and down the limb may yield false negatives or false positives … in other words, if the lameness is caused by a soft tissue problem, it may be missed because radiographs are useful in imaging bony problems. Conversely, there may be a radiographic finding which is not actually responsible for the lameness.
“The other issue here is an ethical one … a veterinarian is a healthcare professional, and as such is ethically responsible to be a good steward of the client's finances. It is not ethical to employ unnecessary diagnostics when a problem may be just as well diagnosed and treated more economically.”
Berk also pointed out an increase in telemedicine, where a veterinarian is asked to review images or test results on a horse they'll never see. In some cases, that's appropriate, when a surgeon is asked to comment on the prognosis of a known fracture, for example. In cases where veterinarians are still fishing for answers, it can be a case of too many cooks in the kitchen.
Just as it's easy to skip straight to the heavier-hitting diagnostic techniques, it's also easy to give them more credence than they deserve. While Verghese worries that doctors aren't listening to their human patients, Berk believes equine veterinarians aren't always doing enough to pick up cues from the horses, or from the horses' owners.
“It can be very helpful to get a good history from a horse owner when that owner is a professional horse person or is at least really “tuned in” to their horse,” Berk said. “Just as important though, listening to the client forms a bond of trust that is important in the process of working through problems with horses.”
The AAEP has made efforts to fill in communication gaps between practitioner and client. The group launched AAEP Touch in 2014, a website aimed at showing veterinarians how to better communicate with and teach clients for improved long-term relationships.
The other challenge is teaching veterinarians how to read body language and behavioral signs from a horse. Some have had more experience with this than others. A study published in the journal Animals earlier this year suggested some veterinary students may struggle to correctly identify equine behavior.
“Unfortunately, students get limited exposure to this type of thing in veterinary schools for a couple of reasons, including a dwindling caseload at most veterinary teaching hospitals and a lack of emphasis on the physical examination in preference for advanced diagnostics at some institutions,” said Berk. “I think it's incumbent upon the individual to learn more about equine behavior.”
That type of exposure to non-veterinary learning about horses can inform a veterinarian about the best way to handle a nervous patient.
“First of all, think about what a horse is. Most of the animals we talk about are divided into two categories. They're a domestic animal or a wild animal. You think of dogs and cats as domestic and a lion or a jaguar as wild. The horse is a unique combination of both of those things,” said Berk. “And because of that, they're very sensitive to their environment and they're very powerful. You need to be sensitive to how the animal's demeanor may be indicative of a physical condition. But you also need to be looking at it from the standpoint of what their comfort level is in being examined and being asked to submit themselves to examination and treatment.”
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