Using Internet Resources for Making Evidence-Based Treatment Decisions
Paul D. Pion, DVM, DipACVIM (Cardiology)
Veterinary Information Network, Inc., Davis, CA
Paul@vin.com | 530-757-6881

Access Access Access!
We live in exciting times. Consider the new recent and future new graduate. They are unique. They represent the first generation of veterinarians who, for their entire career, will be able and expected to practice with instant access to current information and the assistance of colleagues with expertise in all areas.

CANTOR'S LAW OF PRESERVATION OF IGNORANCE A false conclusion once arrived at and widely accepted is not easily dislodged. And the less it is understood, The more tenaciously it is held.

Information is power. All power comes with responsibility and cause for caution. Thus, the opportunity to practice high quality, evidence-based, medicine has never been so widely available.

James is Dead!
The potentially stressful side of this new-found power is that clients will expect more of veterinarians and their practice. Gone are the days that James Herriott can try to be all things to all creatures with 'thanks for trying' being the owner's response when things go wrong after 'making it up as you go along'.

Access to information raises expectations and accountability. Veterinarians have largely practiced without, procedural, legal and financial accountability. Only in cases of extreme malpractice have there been ramifications for being "wrong" or under informed. What the legal profession terms Errors and Omissions.

Today there is growing momentum to hold veterinarians financially responsible for their actions or lack thereof. There is a similar growing momentum to add to simple financial accountability (the cost of the property /animal), the ultimate in legal flexibility to dig deeply into your pocket and raise the cost of your malpractice insurance - pain and suffering. This is the other side of the human-animal bond issue.

As we work to establish, as scientific fact and social norm, that pets truly are intrinsic members of the family unit, we raise the bar for medical care for our patients. But, whether we like it or not, we also raise the bar for how seriously clients and the courts will view real or perceived medical mistakes made upon these family members and the anguish it causes the humans who love them.

We best be ready.

• ready to access the available information
• ready to search the available information
• ready to interpret the available information
• ready to apply the available information
• ready to communicate the available information and most importantly,
• ready to filter the available information

• Personal communication - one to one, one to many, many to many
• Print - e.g., books, journals, class notes, Proceedings of meetings, advertisements
• A major advantage of print is it is simple. It can go anywhere with you (in small doses). You can easily and safely read it in the bathroom J
• Analog Multimedia - e.g., movies, video, sound recordings
• Electronic-offline - all of the above print and multimedia resources on personal computer or in PDA (Personal Digital Assistant) format, plus software (e.g., diagnostic, calculations, testing).
• A major advantage of electronic media is the ability to rapidly search and interact with the information.
• Electronic-online -all of the above print, multimedia and offline resources in unlimited supply, limited only by bandwidth to publish and receive (download) the data
• A major advantage online information provides is the ability to have it constantly updated, annotated, and shared with others; online we are able to instantly "talk back to" and influence the content.
• On a larger scale, a major paradigm shift catalyzed by online technologies is a "leveling effect". No longer are the barriers to publication and worldwide distribution of your thoughts defined in terms of the letters after your name (PhD, DipACVIM, etc). Many of the geographic and social barriers to making personal communication with colleagues a daily activity of veterinarians in practice. Anyone, almost anywhere, can communicate and transmit their thinking on a mass level if they can find a platform upon which others will listen. This paradigm shift brings with it new rules for defining what I call the "responsibility of the lectern".

Interpreting Information
Gaining access to information and learning to effectively search for the information you seek in appropriate sources is an essential skill but not always sufficient to ensure a satisfactory clinical outcome.

• Abstracts are great but don't let you judge for yourself -- most online search engines return citations and abstracts of literature resources. Searching abstracts are great ways to familiarize yourself with the literature, to follow trends and quickly decide what is the "state-of-the-practice". However they do not provide the searcher an opportunity to question the conclusions presented. To judge important issues for yourself, seek out the full-text of the article.
• Reading the full-text requires a strong background, work and skill -- it takes critical reading skills, an understanding of the basic and clinical science involved, experimental design, statistical analysis and interpretation, related literature to truly be able to judge primary literature studies.
• A little knowledge can be a dangerous thing - taken out of context or misinterpreted, the conclusions summarized in research papers or their abstracts can lead to misinterpretation or overinterpretation of the available data.

• It's a long way from the lab to the clinic - many potential treatment strategies sound great in theory and even prove beneficial in well controlled experimental situations but do not translate to effective clinical therapy
• A dog is not a big rat or cat or a small human - effective strategies in one species are wonderful starting places for effective strategies in another species. However species differences are very real and extrapolation across species should be approached cautiously

• Don't believe everything your read
• Be cynical
• The best test is the test of time
• Be a baby bird - seek pre-digested nutrients (err information)

Personally I am simultaneously amused and enamored watching what I always assumed was the practice of MEDICINE re-titled to Evidence-Based Medicine. Amused because in principle I can't imagine anyone NOT striving to practice based upon Best Available Evidence. So why do we need to promote it as something NEW or DIFFERENT? Enamored because I recognize that naming, formalizing, promoting, marketing, -- in essence SELLING and making SEXY or at least POPULAR - the concept is the fastest way to convince others to jump on the BANDWAGON and return to the precepts of MEDICINE based upon SCIENCE while not abandoning the ART of MEDICINE.

In my vision of the world, Evidence Based Medicine, or at least MEDICINE BASED UPON EVIDENCE is as self-evident and natural a concept as the Golden Rule: "Do Unto Others as You Wish Others to Do Unto You". So why all the hoopla about Evidence Based Medicine? Why promote it as a NEW CONCEPT?

Without putting an ethical judgment in the analogy (I don't want to imply that anyone who doesn't live by the tenants of EBM is unethical, I think we can extend the analogy of EBM to the GOLDEN RULE as both being seemingly self-evident principles that do not come naturally to the behavior of all members of society. If the ability and tendency to live by the Golden Rule were an inborn behavior of all people, no matter what they believe is ideal in their heart, then we'd not need laws, police, prosecutors or jails.

Similarly, if the ability and tendency to live by the tenants of EBM were an inborn behavior of all medical practitioners, no matter what they believe is ideal in their heart, then we'd not be having this discussion.

Again, not necessarily a new concept, but one I strongly agree with is that EBM proponents argue that we must ask appropriate clinical questions and place quantitative values upon information we collect. We are at a cross roads in veterinary medicine. We publish huge quantities of information at an ever increasing rate. A proliferation that I attribute largely to the advent of the personal computer and how it has "lowered the barriers" to authoring and publishing.

It is time that we pause and assess not only the presence (quantity) of information available to us also to reflect upon the quality, durability, and source of the information we use.

Quality and source relate to how it was generated and distilled for general consumption. Durability speaks to how it stands the test of time - in theory, in the laboratory, and in practice.

The formal teachings of EBM suggest that the order in which we should give "value" to information is:

Ia Evidence obtained from a meta-analysis of Randomized Controlled Trials
Ib Evidence obtained from at least one Randomized Controlled Trials
IIa Evidence obtained from at least one well-designed, controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed, non-experimental, descriptive studies, such as comparative studies, correlation studies and case-control studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

Beyond the nuts and bolts of searching, which we will cover, the questions I want to explore in the time we have together are:

• How does the internet influence the practice of veterinary medicine?
• What role can / should EBM play in veterinary medicine?

Also at that site are links to 3 papers by Susan Whitaker, Reference/Collection Development Librarian at the Flower-Sprecher Veterinary Library, Cornell University, Ithaca, New York 14853-6401 - Phone: (607) 253-3499 - Fax: (607) 253-3080.

They are:

• Practicing Veterinarians' Guide to E-Journal Access
• PubMed MEDLINE: Overview for Veterinarians
• Current Awareness Updates: PubMed MEDLINE

And finally, and above all, I thank my friends and colleagues for joining me in this semi-spontaneous exercise/demonstration.