Are you an interventionist or non-interventionist?

RE: Are you an interventionist or non-interventionist?

Michael Woodhouse — Wed, 06 Nov 2024 15:57:08 GMT

[quote userid="2131" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245943#245943"]I've always said "I'll see you again in (insert appropriate number) days" and often "but you can ring and cancel the appointment if he's recovered by then".[/quote]

Exactly the same here

RE: Are you an interventionist or non-interventionist?

David Mills — Wed, 06 Nov 2024 15:57:01 GMT

[quote userid="2131" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245943#245943"]

I haven't said that for forty years or so.

I've always said "I'll see you again in (insert appropriate number) days" and often "but you can ring and cancel the appointment if he's recovered by then".

[/quote]

Potato/potato tomato/tomato

RE: Are you an interventionist or non-interventionist?

Evelyn Barbour-Hill — Wed, 06 Nov 2024 15:24:20 GMT

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245882#245882"]Do you never, then, say "come back if it doesn't improve?"[/quote]

I haven't said that for forty years or so.

I've always said "I'll see you again in (insert appropriate number) days" and often "but you can ring and cancel the appointment if he's recovered by then".

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Wed, 06 Nov 2024 10:03:40 GMT

[quote userid="3607" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245918#245918"]

'Presumably it got better then', I said encouragingly - I had heard several other vets jump to that same conclusion in the same circumstance.

'Yeah, perhaps', he pondered, ' ... or perhaps it died ... or perhaps they just thought I was a bit of a twat and went looking for another vet.'

[/quote]

In the practices I work, I find that clients let you know PDQ if something doesn't go to plan, doesn't work, doesn't get better, certainly if it were to die. Usually by way of shouting at reception with numerous 4 letter expletives thrown in, and via a social media bashing.

I always ask when I see them again, "did he go on and recover quickly, or did it take a few days?" etc

Almost never get requests for clinical histories from neighbouring practices, although some will see not ask for them of course.

Maybe we could get better at follow up telephone calls for those we decide not to medicate and advise see how it goes? many practices already do 24-48 hour post op telephone follow up, and clients seem to appreciate this.

RE: Are you an interventionist or non-interventionist?

Malcolm Ness — Mon, 04 Nov 2024 18:41:09 GMT

I recall seeing practice in the 1970s with a vet who, when I asked about a case I had seen with him during my previous visit to the practice a couple of months earlier replied, 'I don't know, the owners didn't bring it back for follow-up.'

'Presumably it got better then', I said encouragingly - I had heard several other vets jump to that same conclusion in the same circumstance.

'Yeah, perhaps', he pondered, ' ... or perhaps it died ... or perhaps they just thought I was a bit of a twat and went looking for another vet.'

RE: Are you an interventionist or non-interventionist?

Alasdair Hotston Moore — Mon, 04 Nov 2024 09:25:17 GMT

What a great thread, I’m primarily a surgeon so unsurprisingly most cases I see get surgery

RE: Are you an interventionist or non-interventionist?

David Mills — Sun, 03 Nov 2024 19:57:42 GMT

[quote userid="5012" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245906#245906"]Why would a discussion about the prescribing trends of POM-V anti-parasitic drugs need to involve RCVS ethics?[/quote]

If you want the results to be published in a journal, you need ethical approval pre study. RCVS provide the service for practitioners not attached to a university (for free)à. It's efficient, thorough and a really positive thing they do.

[quote userid="2100" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245896#245896"]

David Mills I can feel another study coming on

[/quote]

Haha same. At least we can recycle the ethical review stuff make the most out of the work!

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sun, 03 Nov 2024 16:29:27 GMT

[quote userid="2100" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245900#245900"]Steady Clive Ansell our first is still going through rcvs ethics -we'll need to see how well the first one goes before we move onto the second![/quote]

Why would a discussion about the prescribing trends of POM-V anti-parasitic drugs need to involve RCVS ethics?

RE: Are you an interventionist or non-interventionist?

Arlo Guthrie — Sun, 03 Nov 2024 12:29:06 GMT

[quote userid="5012" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245899#245899"]Maybe your study could ask about these?[/quote]

Steady Clive Ansell our first is still going through rcvs ethics -we'll need to see how well the first one goes before we move onto the second!

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sun, 03 Nov 2024 11:06:11 GMT

[quote userid="2100" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245896#245896"]I wonder whether intervention rates change by years qualified, geographical area, type of practice, attitude to risk, health care plans etc. [/quote]

Also changed depending on the drug and the case.

As Michael has said, most of us are probably prescribing far fewer antibiotics than we used too, but on the other hand there is a better understanding and awareness of pain management so these drugs are likely prescibed more? worth asking I guess?

One of my biggest pet hates is the over prescribing of anti parasitic drugs, particularly on corporate health care plans where they are dished out monthly like sweets to kids whether or not they are needed. Maybe your study could ask about these?

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sun, 03 Nov 2024 10:36:05 GMT

Without a doubt.

Anecdote alert.

I remember when I was seeing practine in the early 90's, one of the good old boys used to fill his syringes before starting evening consults - mixture of Amox LA antibiotic, corticosteroid, and vitamin B12, everything got the same purple coloured emulsion; 2 for a cat, 5 for a dog, 10 for a cow, 20 for a horse. Pretty much everything got better or at least didn't come back. I guess most got better because they were going too anyway?

RE: Are you an interventionist or non-interventionist?

Arlo Guthrie — Sun, 03 Nov 2024 10:25:22 GMT

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist"]

Quite afternoon here and I've just looked over my last 40 cases (non vaccine, rpt meds etc) to see how many time I prescribe any meds.

35%.

[/quote]

David Mills I can feel another study coming on

I wonder whether intervention rates change by years qualified, geographical area, type of practice, attitude to risk, health care plans etc.

Would of course be fascinating (and possibly instructive) to monitor the consequence, but much more difficult.

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sun, 03 Nov 2024 09:48:42 GMT

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245882#245882"]Has no-one else seen the relief on clients' faces when they realise their dog a) has something mild and self-limiting; b) won't have to shell out more money for meds; c) can judge the non-intervention's success at home with some guidance?[/quote]

Yes, all the time. If I feel medication isn't needed, thats is what I advise. As you say, most of these don't come back so we all assume they are OK and we were right.

The problem, is the ones that do have to come back and start kicking off about paying another (currently £67.50) consultation fee. Sometimes I will say "if he/she is not better in 2,3 or 5 days you can call and request Metacam, or a Probiotic (unsure if these actually do anything?) ect"

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245882#245882"]What evidence do we have for most tings we do? Not much. "Clinical experience" - based mainly on animals not coming back, despite our apparently homeopathic approach.[/quote]

Maybe we need to get better at obtaining, recording and analysing follow up data?

Maybe for the ones we don't prescribe any medications, a telephone call from reception or an email follow up would be a good idea?

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sun, 03 Nov 2024 09:39:23 GMT

[quote userid="24356" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245892#245892"]It'll be interesting to see if less meds are prescribed for patients on health care plans with consults included.[/quote]

Whether consultations are included or not on a health care plan, shouldn't make any difference to a prescribing decision of course.

It maybe thought, where consultations are included, cases will present earlier that than otherwise would, sometimes where medications are not, or not yet, needed and the patient gets better anyway (mild GI cases etc)

RE: Are you an interventionist or non-interventionist?

Elizabeth — Sun, 03 Nov 2024 09:00:25 GMT

It'll be interesting to see if less meds are prescribed for patients on health care plans with consults included.

RE: Are you an interventionist or non-interventionist?

David Mills — Sat, 02 Nov 2024 09:05:31 GMT

[quote userid="12930" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245875#245875"]I would be upset with my receptionists if they let two-thirds of my consults be filled up with things needing no treatment.[/quote]

Why?

They shouldn't really be triaging. We are a service industry. Therefore rightfully beholden to clients accessing and paying for a service. We're not the NHS.

[quote userid="11493" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245876#245876"]Once I was told by an homeopath that their treatment really worked. [/quote]

You should probably get better friends.

[quote userid="11493" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245876#245876"]but that's not how I judge success. [/quote]

Some people bring problems, others solutions. Do you never, then, say "come back if it doesn't improve?"

[quote userid="3169" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245878#245878"][very low - taken paracetamol today][/quote]

Soft arse.

[quote userid="3169" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245878#245878"]That's why they are in front of you.[/quote]

Are they? How do you know? Maybe they just want reassurance it is a mild, transient, issue that they don't need to spend £20-30 treating unnecessarily.

[quote userid="24356" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245879#245879"]If someone is paying £60 for you to make their dog better, they're usually less happy to wait and see, with another consult fee before they get medication. [/quote]

Again, see above. Have you asked them? Who is creating this "we should do something" attitude?

On one hand you hear that 70% of things get better despite intervention.

On the other the bean counters say things should never leave without a tablet or injection.

What evidence do we have for most tings we do? Not much. "Clinical experience" - based mainly on animals not coming back, despite our apparently homeopathic approach. Extrapolation - do you think your GP would give you anti-emetics for a transient GE? No.

[quote userid="5012" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245881#245881"]It isn't, it is £60 for a consultation, to take a history, perform an examination and discuss the findings and formulate a plan. [/quote]

Why don't more people think like this?

Someone above said they only really want to see sick animals and would be "annoyed" if the were seeing mild cases. Why?

[quote userid="5012" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245880#245880"]I guess it will vary greatly on where one is working, and the type of practice and clients? chalk and cheese. [/quote]

Indeed. But there is an uncomfortable issue with the "worried well" in that I bet at leas 2/3s leave with something injected or prescribed - in fact probably around 75-90%.

Has no-one else seen the relief on clients' faces when they realise their dog a) has something mild and self-limiting; b) won't have to shell out more money for meds; c) can judge the non-intervention's success at home with some guidance?

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sat, 02 Nov 2024 08:43:38 GMT

[quote userid="24356" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist/245879#245879"]I think consultation fee is also a factor. If someone is paying £60 for you to make their dog better, they're usually less happy to wait and see, with another consult fee before they get medication. [/quote]

I think you're right.

One of the commonest questions I get is "do/why should I have to pay if I need to come back?" Also, some practices have dropped the re-exam consultation charge and charge a full fee for all repeat consultations now.

They and us need to get away from the mindset, that is £60 to fix their dog. It isn't, it is £60 for a consultation, to take a history, perform an examination and discuss the findings and formulate a plan.

RE: Are you an interventionist or non-interventionist?

Clive Ansell — Sat, 02 Nov 2024 08:36:19 GMT

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist"]What are other people's?[/quote]

Quick flick back through the diary, and cases this week about 65%, 2 in every 3 roughly.

I guess it will vary greatly on where one is working, and the type of practice and clients? chalk and cheese.

In the poorer areas I work most of the time, we rarely see trivial things that don't really need seeing, and cases we do see are presented in a much more advanced state - folk have no money and put things off as long as possible - when they do finally present they are usually in dire need of some intervention. These clients don't want an in depth discussion about antibiotic resistance etc, they want a quick fix at minimal cost and effort

On the other hand; 2 independents I work for in more affluent areas, the clients are more educated, questioning and demanding. They want a thorough consultation and discussion, and are not content with the obligatory Synulox and pred/nsaid fob off. They want to discuss diagnostic options, and reasoning and justification to prescribe meds. I have found more are question the (mis)use of antibiotics over time, which is good thing overall, but can be demanding and tiresome sometimes. Many of the cases are less advanced, so often only observation and no treatment is indicated. Also many more trivial (to me, not the owner) cases; dog that has sneezed once in 3 weeks, or an hour later eating his breakfast.

RE: Are you an interventionist or non-interventionist?

Elizabeth — Sat, 02 Nov 2024 06:13:40 GMT

I think consultation fee is also a factor. If someone is paying £60 for you to make their dog better, they're usually less happy to wait and see, with another consult fee before they get medication.

RE: Are you an interventionist or non-interventionist?

Michael Woodhouse — Fri, 01 Nov 2024 23:42:49 GMT

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist"]What are other people's?[/quote]

I think you also need to add in a couple of extra questions -

What is your threshold for taking analgesia in your self? [very low - taken paracetamol today]

When did you last make a doctors appointment? [a long time ago]

When did you last take OTC medication yourself? [decongestant today - joys of children]

I'm very much in the camp of if it hurts me I'll take something for it.

A dog with a limp is in some pain and if I was limping I'd take NSAIDs. Inflamed ear would get a minimum of steroids from me. Skin inflammation some steroid cream (or due to the cascade likely some fucidic acid too....). Be rare to see a dog with vomit or diarrhoea that I didn't give some maropitant.

I have a very high threshold for prescribing antibioitcs, but an exceptionally low threshold for prescribing things that I think will (or may) make the animal feel better. That's why they are in front of you.

RE: Are you an interventionist or non-interventionist?

Francisco Gomez — Fri, 01 Nov 2024 22:48:43 GMT

[quote userid="8991" url="~/f/clinical-questions/31073/are-you-an-interventionist-or-non-interventionist"]None of those where I haven't prescribed anything (e.g. mild limps, mild localised skin inflammation, mild ear inflammation) have com back requiring treatment. [/quote]

Once I was told by an homeopath that their treatment really worked. Not needing to come back was their proof.

I am by default non interventionist, but that's not how I judge success.

RE: Are you an interventionist or non-interventionist?

Beats — Fri, 01 Nov 2024 20:57:47 GMT

interesting q.

I haven't looked, but would guess i'm way above 35% from what gets into my consult room.

I would be upset with my receptionists if they let two-thirds of my consults be filled up with things needing no treatment.

I do also use a lot of one-off steroid injections though... so that's going to put my percentage higher than that for sure even if we shared the same receptionists.