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Monday, December 14, 2009

Practice Makes Perfect

Being a doctor isn't easy, and I don't think anyone would disagree with this comment. One of the hardest things to learn is how to take the information from the classroom and textbooks and apply it in a clinical setting.  This is why experienced doctors tend to make better clinical judgements than new graduates (everything else being equal).  It may not seem like it, but there can be a bit of disconnect between what is reported in the texts and what you may actually see.

It's common for doctors to talk about whether or not a patient "reads the textbook". This means that some cases present exactly like is described in the textbook.  For example, a hypothyroid patient would have a thinning coat, weight gain, and persistent skin infections.  However, some cases don't have classic characteristics, such as a diabetic patient without an increase in drinking or urinating.  It's easy for a doctor to read symptoms and lab results in a book or class notes and figure out what the disease is and how to treat it.  However, if the patient doesn't have all of the symptoms, or has some conflicting lab results, it can be difficult to make conclusions.  That's where experience and learned clinical judgement comes into play.

There is an art to medicine.  It takes experience to learn how to interpret lab results, determine what treatment is best, and how to implement that.  Lab results do not stand apart from the patient.  Two patients can have the same lab values but look and act differently. Conversely, you can have two patients with the same basic symptoms but radically different lab results.  You can have the same disease that presents in several different ways.  A newly graduated doctor has an incredible amount of "book knowledge", and knows a lot.  But they haven't learned how to apply that knowledge.  There is absolutely no way to teach this.  It only comes from seeing enough cases to learn the wide variety of presenting symptoms and clinical outcomes.

Believe me, this isn't disparaging newly graduated doctors.  Every single doctor was a "new grad" at one point, myself included.  I have had to learn many lessons of the years, and am a better doctor for it.  At the same time, I enjoy mentoring newer doctors as I always learn something from them. 

One reason for this entry is to caution laypeople about reading journal articles and text books and then interpreting their cases.  Yes, many times you can learn a lot and I don't discourage.  I also encourage people to be well-informed, ask their doctor lots of questions, and keep copies of lab results and medical notes.  But you have to be cautious in interpreting this information in light of your particular case. There is a reason why becoming a doctor takes years of intense education and why an experienced doctor's judgement is so critical.  Now, this doesn't mean that a given doctor will always be right...we're only human after all, and it's impossible to make perfect decisions every time.  But in general, an experienced doctor will know more than a new graduate and both will be able to handle cases better than a layperson.

For the educated layperson, this means that you should ask even more questions.  Like I mentioned last time, there is nothing wrong with respectfully questioning the "whys" of your doctor's decisions.  But a little knowledge can be a dangerous thing, and you should realize that no matter how much you read, this information can never compare to a doctor with the same information and years of experience.


  1. While a layperson is certainly not a vet, and you would think that the professional should know what to do, I would still caution against blind trust. Do your own due diligence. Failure to do so could result in you getting lucky or .... disaster. Stempy does not get a second chance.

  2. Dr. Bern,

    I know this is a little off topic, but it just concerns me a little bit that you refer people to a cash advance. I know people may be hard up, but have you seen the terms on those payday loans? You sure you couldn't work out a payment plan with some of them? LOL. Seriously.

  3. I agree with your comments Greg. Hopefully a vet will know more than their clients...after all, that's kind of the point. And an educated client should ask plenty of questions, and expect the vet to be able to answer them (though in some cases the vet may have to look up some things if the question is extremely detailed or odd...this is normal of any doctor).

    Overall, I also agree with the payday loans, and would never use one myself. That particular part of the sidebar is actually a paid advertisement that I have agreed to let stay up for a year (already about halfway done). After that year I may not renew it because of my own feelings on the issue.

  4. Dr. Bern, Seriously? Do you feel that laypeople cannot understand medical journals? Well, they might not engage in a long dissertation, but surely all the articles brought down to simple basics, such as Tufts mag, Cornell's Your Dog, etc. is certainly informative without being overwhelming.

    Don't discredit the layperson, the majority of us are at the age we are traipsing along with our elderly parents to specialist after specialist and forced to become medically savvy.

    I enjoyed this article, but if you think that it is going to soothe the new grads or the experienced "old grads" into the previous world of complacency, it won't!

    I tried to ask you what an extreme phosphorus value meant the other day, and instead of saying "oops, not too good", it took teeth pulling to finally get down to brass tacks.

    What is the simple answer? "If the pet can no longer regulate phosphorus & eliminate the excess from the body, 'we' are in deep doodoo".

    I know you are familiar with why this such a sore spot with me. My pet suffered because some educated DACVIM was simply withholding important knowledge & furthermore was dishonest ON TOP OF IT!

    These end-of-life scams & lepto scares and terminal surgeries (when you know the pet has very little chance to even recover from the surgery--- have got to stop!

    And to echo GregM, if you are not proficient in a particular surgery, don't keep that a big secret either.

    I posted a new 101, if you should like to expand on that one.

    Oh, back on topic. I have no qualms working with a newbie, oldie, or whatever---as long as they are honest, considerate, and willing to consult resources & refer when beneficial for the patient. Simple!

  5. Barbara, once again you misunderstood my comments. I never once EVER stated that a layperson could not understand a medical journal. Not once. My entire point was that there can be a disconnect between what is listed in the journals or texts and how that applies to the case in front of you. That kind of interpretation is something that laypeople and new graduates have a hard time with, and I was merely cautioning about this.

    Also, I have NEVER tried to encourage anybody into complacency. If you got this out of my comments, then you completely misunderstood.

    As far as your previous question on specifically asked me what the highest value reported was. I answered that to the best of my ability. It wasn't until further in our discussion that we got down to what you were really asking. I can only try to answer the questions I'm given, not interpret the meaning behind them.

    I agree that if you are not proficient in a surgery that you shouldn't say that you are. This is all about honesty and I've been faced with making this statement myself (which I gladly do if I'm really not skilled at a given procedure).

  6. Lay people are sometimes MORE intelligent than the vets themselves. I agree that medicine is an art BUT not ever vet (or doctor) is an artist! Some vets should get OUT of this business. They are dishonest, do not care about animals, are in it for money and ego.(I am not inferring that upon this author...I do not know him). Dishonest, greedy vets need to lose their license. All the questions in the world do not help with you have a vet LYING to you.

  7. Wow, I know that people have had bad experiences, but please, people, let's have a bit of perspective. Go back and read my other posts and comments over the last week. And read my posts carefully!

    Yes, dishonest, incompetent, and greedy vets need to have their license revoked and be out of business. But this is true of ANY profession! And I know that some people have had truly horrible and unnecessary experiences, but believe it or not, these are the minority of cases (regardless of which numbers you use). Any case is too much, but let's not bash everyone.

    And ONCE AGAIN, my point was NOT that laypeople are not intelligent. It's just that "book learning" needs to be combined with practical experience to be truly useful.

  8. It is interesting that you should say that. I am a huge fan of webmd, but the issue is that I tend to self diagnose myself way more often than I should, instead of going to the dr. myself. I usually end up suffering through something that if I simply went to the dr first could have been easily solved. On the flip side of this, I have also learned a great deal about various issues and illnesses and feel better informed and know what kind of questions to ask because I have done my homework first. So that I how I interpreted this. I think that it is well said, and there is no way that I would want to have the pressures that the drs face everyday to be perfect.

    I appreciate your honesty on all issues and am an avid reader of your blog. Thanks for all you do to put up with the people like me that will ask a million questions just because I want to know it all. ;)

  9. Well, at least we are keeping you on your toes!

    I agree with your blog in total, and that is what can be so entirely frustrating for both the clinician & client/patient.

    Some vague symptoms may be obvious, but what is the problem--or some lab work may lead down the wrong path in combination with vague symptoms.

    For example, my dearly loved Pocket was "euthyroid sick" early on at about 2yrs of age. She didn't have the labwork to entirely support the diagnosis, but sure had the symptoms.

    I was so completely frustrated and finally asked, "please, can we try the treatment anyways?" Sure enough, it was the answer.

    I agree with you, there are no easy answers, all of the time. Sometimes it is so obscure or unusual, that it may take months to get to root of the problem or you may never discover it!

    I guess I just took you up on the "...caution laypeople about reading journal articles and text books and then interpreting their cases..." comment.

    I have absolutely NO doubt that my Scottie had some form of cancer : lymphoma being the #1 and TCC being #2 in the breed, and no doubt that my Scottie presented with enough lab, x-rays, physical presentation to enable the LEAST educated vet-doc that she was in total system "failure", and that giving her IV water was doing absolutely NOTHING to help her.

    If there is any elderly dog out there with her initial blood results, and subsequent blood results after 18 hours that has ever successfully went on to LIVE, I'll eat my socks!

    Ok, your turn to critique my Lepto 101 article---fire away!

  10. If it's true that self-education through internet research can never compare with a degreed, experienced vet, then can you please explain to me why the cat owners on the feline diabetes message board ( have saved hundreds of cats' lives by when their vet's recommendations are outmoded, outdated, and flat out wrong and dangerous?

    Why do many vets persist in asserting that oral hypoglycemic agents are an acceptable first approach when they are not?

    Why do they persist in handing owners a bag of DRY prescription food, and starting the cat out on HIGH doses of short-acting insulin with NO home testing?

    Why do they tell owners that home testing is either not necessary, innaccurate, or worse, dangerous? (One even led an owner to believe her cat might bleed to death from its ear)?

    Why do many of them demand that cats be "regulated in the hospital" before going home on diagnosis, when the cat does NOT have ketones and everyone knows that "vet stress" can cause artifically high bgs in both diabetics and non-diabetics?

    Why do they use that horrible short acting humulin N or vetsulin and keep raising, raising, raising doses with NO home testing and sometimes even no curves, just an in-office test?

    Why do some of them persist in pushing the Alpha Trak veterinary meter when some human meters are just as accurate on cats and all human meters are cheaper?

    Why do some vets recommend euthanasia on diagnosis? With cats that don't have ketones?

    Nope. While there are a minority of vets out there who are good partners in dealing with a diabetic pet, the majority of them -- or AT LEAST half -- are still stuck in the dark ages and if it weren't for internet research and communication many more pets would be sicker or dead as a result.


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