Picture is of two Mexican dogs that pulled through and have great homes. They remind me why I do what I do. I have just finished a book called Complications: A Surgeon's Notes on an Imperfect Science, by Atul Gawande. He says, "It is because intuition sometimes succeeds that we don't know what to do with it. Such successes are not quite the result of logical thinking. But they are not the results of mere luck, either." I call it the 'Gestalt' of medicine (I stole that from the Gestalt of bird watching, but I think the concept can be applied to nearly any field. It has to do with listening to your gut.)
Gestalt: a structure, configuration, or pattern of physical, biological, or psychological phenomena so integrated as to constitute a functional unit with properties not derivable by summation of its parts. What this really means is: when you see a square, you recognize it as a square. You don't have to compute mentally the four lines that comprise the square before proclaiming it as a square. People want doctors and veterinarians to be masters of Gestaltism. See sick animal and proclaim, "pancreatitis!" without any further ado.
But, medicine is not cut-and-dry. For example, a cat had come in to see me for ADR (Ain't doin' right). The cat was somewhat feral and would tolerate only a superficial exam before coming at me, teeth-bared and claws slashing. My superficial exam revealed only moderate ear infections, possibly ear mites, and nothing else. We had a choice to make.
Were this my cat, I would treat with antibiotics and ear meds for a few days and see if the symptoms resolved. I would be knowingly taking a chance that the cat would get worse or even die due to the lack of a complete exam. I offered the owner two options: 1. we anesthetize the cat for a full workup or 2. we try the medications. The owner said, "You're the doctor. You know best."
In vet school, as in med school, we are taught "Primum non nocere," which means "First, do no harm." I knew with the sub-optimal anesthesia we'd be forced to use on this whirling dirvish, a certain amount of harm would be unavoidable. I suspected, in my gut, that this cat was having a few "off" days and would rally if his ears were treated. I decided to listen to that impulse. I squared my shoulders and told the owner I'd recommend trial treatment for no longer than two days; if at that point the cat was still feeling puny, we'd anesthetize and continue diagnostics. We did so, and the cat, on the last call-back, was doing great. Thank goodness.
The owner's assumption that I should be able to decide the course of action because I am the "doctor" is essentially a human paradigm: the doctor knows best. However, human patients can be examined; feral cats cannot. When I, with my DVM, peer at a growling ADR feline through Have-A-Heart trap cage bars, I do not see any more of the pathology than the owner does. I see a pissed-off cat with sharp bacteria-laden canines and the potential to do some serious damage to me and my staff (think hospitalization and IV antibiotics and large WC claims). Due to my lack of xray vision, I often put the onus back on the owner to decide the risk vs. the benefit. Should we risk the anesthesia in order to take samples, examine, and treat? Or should we decrease stress (and therefore avoid depressing immune function) by sending the pet home with a barage of empirical treatments?
This is the Gestalt of veterinary medicine, the sum of all the clinical signs and tests and findings. When is the risk worth the benefit? When do you push a client towards spending money on diagnostics and when do you support them in their choice to try the less-expensive Option B? When do you say definitively, "This dog needs $2000 worth of emergency surgery!" vs. waiting it out to see if the situation improves?
I read occasionally on the internet (masochistic, I know) about how vets should be like doctors. We should be able to prescribe medications for ailments without running every test in the book. I had an older couple who brought their ancient Labrador in for me to determine what was causing her to vomit. I examined her, described what I thought might be going on, and asked permission to get some radiographs. The elderly owners looked down at me as I sat stroking their dog's head in my lap, and said, not unkindly, "Our old doc used to be able to just look at our animals and know what was wrong. I guess they don't teach you young doctors that in school anymore, eh?" With my heart dropping, I said, "No, that's a specific talent that I still don't have." My boss, bless him, laughed when I told him this story, and told me that after 40 years in practice, he didn't have that talent either.
As I spend time in the field, I have started to develop a certain model of practice that allows me eventually to find the Gestalt of a particular case. Some days, my gut instincts diagnose correctly right-and-left, and I am left euphoric at the end of the day. Veterinary superhero! But, most days, I am confronted repeately with the fact that my best guess is not good enough, and many times, takes me further from the truth. And I have pledged: Primum non nocere. So, dutifully, I use my diagnostics first, running radiographs and blood work, doing ultrasounds and surgery. When all the results point fuzzily in different directions, I call almost spiritually on the Gestalt of veterinary medicine (and the specialists on VIN) to guide me towards the most likely path. Like Atul Gawande says, medicine is an "imperfect science," and I am unfortunately an imperfect veterinarian.
"The thing that still startles me is how fundamentally human an endeavor it is. Usually, when we think about medicine and its remarkable abilities, what comes to mind is the science and all it has given us to fight sickness and misery: the tests, the machines, the drugs, the procedures. And without question, these are at the center of virtually everything medicine achieves. But we rarely see how it all actually works. You have a cough that won't go away - and then? It's not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he's still trying to learn."
Gestalt: a structure, configuration, or pattern of physical, biological, or psychological phenomena so integrated as to constitute a functional unit with properties not derivable by summation of its parts. What this really means is: when you see a square, you recognize it as a square. You don't have to compute mentally the four lines that comprise the square before proclaiming it as a square. People want doctors and veterinarians to be masters of Gestaltism. See sick animal and proclaim, "pancreatitis!" without any further ado.
But, medicine is not cut-and-dry. For example, a cat had come in to see me for ADR (Ain't doin' right). The cat was somewhat feral and would tolerate only a superficial exam before coming at me, teeth-bared and claws slashing. My superficial exam revealed only moderate ear infections, possibly ear mites, and nothing else. We had a choice to make.
Were this my cat, I would treat with antibiotics and ear meds for a few days and see if the symptoms resolved. I would be knowingly taking a chance that the cat would get worse or even die due to the lack of a complete exam. I offered the owner two options: 1. we anesthetize the cat for a full workup or 2. we try the medications. The owner said, "You're the doctor. You know best."
In vet school, as in med school, we are taught "Primum non nocere," which means "First, do no harm." I knew with the sub-optimal anesthesia we'd be forced to use on this whirling dirvish, a certain amount of harm would be unavoidable. I suspected, in my gut, that this cat was having a few "off" days and would rally if his ears were treated. I decided to listen to that impulse. I squared my shoulders and told the owner I'd recommend trial treatment for no longer than two days; if at that point the cat was still feeling puny, we'd anesthetize and continue diagnostics. We did so, and the cat, on the last call-back, was doing great. Thank goodness.
The owner's assumption that I should be able to decide the course of action because I am the "doctor" is essentially a human paradigm: the doctor knows best. However, human patients can be examined; feral cats cannot. When I, with my DVM, peer at a growling ADR feline through Have-A-Heart trap cage bars, I do not see any more of the pathology than the owner does. I see a pissed-off cat with sharp bacteria-laden canines and the potential to do some serious damage to me and my staff (think hospitalization and IV antibiotics and large WC claims). Due to my lack of xray vision, I often put the onus back on the owner to decide the risk vs. the benefit. Should we risk the anesthesia in order to take samples, examine, and treat? Or should we decrease stress (and therefore avoid depressing immune function) by sending the pet home with a barage of empirical treatments?
This is the Gestalt of veterinary medicine, the sum of all the clinical signs and tests and findings. When is the risk worth the benefit? When do you push a client towards spending money on diagnostics and when do you support them in their choice to try the less-expensive Option B? When do you say definitively, "This dog needs $2000 worth of emergency surgery!" vs. waiting it out to see if the situation improves?
I read occasionally on the internet (masochistic, I know) about how vets should be like doctors. We should be able to prescribe medications for ailments without running every test in the book. I had an older couple who brought their ancient Labrador in for me to determine what was causing her to vomit. I examined her, described what I thought might be going on, and asked permission to get some radiographs. The elderly owners looked down at me as I sat stroking their dog's head in my lap, and said, not unkindly, "Our old doc used to be able to just look at our animals and know what was wrong. I guess they don't teach you young doctors that in school anymore, eh?" With my heart dropping, I said, "No, that's a specific talent that I still don't have." My boss, bless him, laughed when I told him this story, and told me that after 40 years in practice, he didn't have that talent either.
As I spend time in the field, I have started to develop a certain model of practice that allows me eventually to find the Gestalt of a particular case. Some days, my gut instincts diagnose correctly right-and-left, and I am left euphoric at the end of the day. Veterinary superhero! But, most days, I am confronted repeately with the fact that my best guess is not good enough, and many times, takes me further from the truth. And I have pledged: Primum non nocere. So, dutifully, I use my diagnostics first, running radiographs and blood work, doing ultrasounds and surgery. When all the results point fuzzily in different directions, I call almost spiritually on the Gestalt of veterinary medicine (and the specialists on VIN) to guide me towards the most likely path. Like Atul Gawande says, medicine is an "imperfect science," and I am unfortunately an imperfect veterinarian.
"The thing that still startles me is how fundamentally human an endeavor it is. Usually, when we think about medicine and its remarkable abilities, what comes to mind is the science and all it has given us to fight sickness and misery: the tests, the machines, the drugs, the procedures. And without question, these are at the center of virtually everything medicine achieves. But we rarely see how it all actually works. You have a cough that won't go away - and then? It's not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he's still trying to learn."
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