An Inconvenient truth - guest blog by Ian Nicholson
An inconvenient truth
“With a few exceptions (!), vets are amazingly versatile, hard-working, resourceful, and kind people, doing a highly complex job in emotional circumstances — day in, day out.
I've worked in mixed practice, farm, equine, and finally small animal. I’ve gone through rotating internship, surgical residency, university house surgeon, private multi-disciplinary referral, private first-opinion/referral, and now opened my own first-opinion/referral practice with a friend, all the while trying to do some teaching and clinical research too. The thing that has stuck out for me has been the fact that I've seen the same mistakes repeated the country over, the same (mis)information repeated time and again, and it has made me wonder: how can it can be that a profession that claims to be science-led can rely on non-scientific knowledge-transfer the vast majority of the time?
“How can it can be that a profession that claims to be science-led can rely on non-scientific knowledge-transfer the vast majority of the time?”
What do I mean by this? Well - how do we deal with new clinical situations, where we find ourselves in a position where we don't know what to do? Do we work scientifically, exploring data meticulously and systematically, with an eye on the amount of bias inherent in it? Or do we just ask whoever we trust who is closest by, and go with what they say if it sounds plausible - essentially allowing us to display herd behaviour?! This herd behaviour starts in earnest when we start our working life - there is so much to try to learn all at once that we grope around for the quickest support and solution — by asking our boss and colleagues. There's no time to look for evidence, we can't apply any evidence to ourselves anyway because we are so inexperienced we will always do worse than what is published! In general we end up doing what they do, and it kind of works so we keep doing it. Unless we get out of this echo chamber, we then become part of the problem, trading on memes!
There are so many memes that perpetuate despite them being based on nothing at all - and these dictate the decisions of most of us. "Don't turn a dog "legs over" otherwise it will get GDV" is a good one - and total rubbish! But everyone, and I mean everyone, will struggle to lift an anaesthetised 80kg St Bernard to turn it "legs under" (risking their own back health) based on this fallacy. Even if one looks at this theoretically it falls down immediately - GDV stomachs almost always twist "clockwise" as one looks from the dog’s pelvis up to its head, and so in theory turning a dog "anticlockwise" could "leave its stomach where it was and turn the dog around its stomach, inducing GDV". Turning a dog "anticlockwise" would mean turning a dog from left lateral recumbency "legs over" to right lateral recumbency - OR would mean turning a dog from right lateral recumbency "legs UNDER" to left lateral recumbency! Which is what, half the time, well-meaning vets are doing "to try to prevent dogs getting GDV". Crazy, no?! It's just one example - there are many more serious ones out there - i.e. all of wound care, "suture reaction" (aka infection, but it's not good for business to call it this) - I mean, the dog has just reacted to the suture, nothing I could do about it, nothing to do with my own surgical techniques and processes....But let's just give some antibiotics to help calm it down"!!!
So what is there to do about this? How can one break out of this cycle, when we work for a small business with no spare time and precious little spare money, where it's hardly a priority to waste time questioning what we're doing when we could just whip through life doing the same things we've always done, turn over the most, get a bonus, live a bit more comfortably.……?! It's hard, and there's no one solution — other than that which we all have within ourselves — the desire to do the best job we can, every time. Maybe we need to remind ourselves that there ARE other ways of finding things out, that can give us quick answers to at least some of our questions.
Veterinary Prescriber is one of these things, and it is my pleasure to try to help Andrea and Carl with their business, selling refined information to those who really do need it (and there are so many who just don't know it yet!).
There are others. You can just put a link to these on your smartphone and use them every day. Just go to the web-site on your phone, and touch the square/arrow "send" button on your screen, then choose "Add to Home Screen". Done. Easy. Now you've just got to give them a try!
Veterinary Systematic Reviews a free site which does what it says on the tin. You can access all known veterinary systematic reviews here - and these are the least biased information source available, so if there is one for the topic you're interested in, then it is normally strong evidence.
Veterinary Evidence where Knowledge Summaries are made and shared, which research everyday questions and come up with everyday answers. Sadly, a lot of the time the answer is "there's not enough good-quality published information available", but it's a start!
Best Bets for Vets. Similar to Knowledge Summaries, normally an interesting read, and if you're trying to work out what to do, it's quick to look here to see if somebody has already answered your question scientifically.
RCVS Knowledge's library. £125 per year, less for younger vets, and it really is super-easy to search for all relevant, published papers within seconds, scan titles and abstracts within 2 minutes, and download key papers as needed. It includes CAB abstracts, the widest search engine for veterinary papers. There are excellent instructions about how to do this on RCVS Knowledge's site https://knowledge.rcvs.org.uk/document-library/ebvm-toolkit-2-finding-the-best-available-evidence/.
Vet Audit has collected data on routine canine and feline neutering complication rates. Practices can compare their complications statistics with the benchmark rates.
BSAVA's new library resource. £236 per year full membership, less for younger vets. This centralises all BSAVA's accumulated publications and includes CAB abstracts.
By the way, "science" can be a bit of a turn-off, especially if it makes one think of "experimenting on animals" which none of us have any desire to do (perhaps with the exception of certain notorious individuals). "Scientific" refers to an approach — open, thorough, systematic, logical, observational, aware of bias — that we can all employ.
All this is just a start, but by being a bit more scientific about how we answer everyday questions it soon becomes easier, forms a new habit, inspires those around us to do the same (when they see it is quick, easy, and useful), and after that who knows?! Maybe we could all be a bit more scientific about how we work in general, and systematically record and review our own results, then make positive changes to our own practice based on our own case data? Maybe we could even share our case data with others, in order to benchmark ourselves and to help find out what really works, what makes the difference between somebody getting excellent results and someone just getting OK ones?! Who knows where that might lead? Maybe we could even start to fill all those gaps found by all the literature reviews (above) and then answer all the questions we all have about how to do a better job — and genuinely become a science-based profession, working to better itself for the benefit of all the animals and all owners/keepers. And it won't be bad for our own well-being too.”
About Ian Nicholson: Ian has been a RCVS and European specialist in Small Animal Surgery since 2011, having qualified from Bristol in 2000 and spent time in mixed practice, locuming/travelling, and small animal practice, before doing an internship (RVC) and residency (Cambridge). He set up the AVSTS Research Cooperative to try to help vets work together to publish bigger and more relevant studies, and works on the BSAVA Scientific Committee to help put science (systematic and meticulous observation, recording, sharing and reflection, aka evidence-based veterinary medicine) into the centre of veterinary life. He set up a practice with a friend on the Isle of Wight, Island VetCare Ltd, and does consultancy and educational work via Petsmiths Ltd. He has a young family and enjoys sailing around the Solent with them.
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