Treatment off the internet

Re: Treatment off the internet

vs0u — Tue, 25 Sep 2012 17:00:31 GMT

The guinea pig example was meant to demonstrate that clients have no problem with internet info. I didn't mean to say that every client brings in pages off google - obviously not! sorry if it wasn't clear!

Have you had issues with clients questioning your information sources?

Do you personally tell clients where you get your information from during every consult?

(yes or no answers probably easiest for me to understand - just wondering why you think this is an issue)

[quote user="J G Wray"]All clients expect us to use the best quality information. What they expect, I think, is that we apply a filter to the sourcing to achieve the best. [/quote]

I agree

Re: Treatment off the internet

Bob Russell — Tue, 25 Sep 2012 11:16:26 GMT

A client has just told me that her dog needs neck X-rays! Chiropractor recommendation of course!!

This has to be sound EBM.

Re: Treatment off the internet

Mark Hedberg — Tue, 25 Sep 2012 07:32:40 GMT

No fair dodging, answer the question! ;)

Re: Treatment off the internet

J G Wray — Tue, 25 Sep 2012 07:29:35 GMT

Dear Ms Howell,

[quote user="alison howell"]I had a client yesterday concerned I didn't know how to treat his guinea pig, bring in 5 pages printed off google for me.[/quote]

Yup, that's the 21st Century

[quote user="alison howell"]And many clients seem to think their breeder/next door neighbour knows something important. [/quote]

..and don't forget the man in the pub - 'twas ever thus.

[quote user="alison howell"]I truly believe clients expect us to use as many information sources as necessary and don't have any problem at all with info off the internet, including this forum (and when I tell them I have got information from a veterinary forum they are always very pleased I am taking their animal's case seriously)[/quote]

I don't think any client comes in to us to experience our urbane wit and charm for 15 mins and pay the same money as they would up West for a three hour show. Your focus should be the person right in front of you when you are consulting and their patient. If you need to convince your clients you are are taking them seriously, then flitting about the Internet ain't an issue.

As for sourcing information, then this is a non argument. All clients expect us to use the best quality information. What they expect, I think, is that we apply a filter to the sourcing to achieve the best. When we use any source we are adding our personal, professional imprimatur and if we represent something as authoritative, by implication, when it is not then.....

[quote user="alison howell"]Do you personally tell clients where you get your information from during every consult?[/quote]

You've made an example of one guinea pig consultation. I don't think you have clients coming for "every consult" with their own googlinfo, so I'm not quite sure how you are going from the n=1 to "every consult".

Did you charge the guinea pig owner a consultation fee? If not, then you could probably have charged a "Access to medication and surgery fee"

JGW

Re: Treatment off the internet

vs0u — Mon, 24 Sep 2012 20:44:52 GMT

[quote user="J G Wray"]I think it would be weird to rely on treatment recommended on an internet discussion group like this and most contributors seem to feel they don't. What's not clear is how many tell their owners where they source information, or seem to feel it might be incumbent on them to do so, should they be asked.[/quote]

I had a client yesterday concerned I didn't know how to treat his guinea pig, bring in 5 pages printed off google for me. And many clients seem to think their breeder/next door neighbour knows something important. I truly believe clients expect us to use as many information sources as necessary and don't have any problem at all with info off the internet, including this forum (and when I tell them I have got information from a veterinary forum they are always very pleased I am taking their animal's case seriously)

Do you personally tell clients where you get your information from during every consult? Have you ever had an adverse reaction if you said you looked something up online/used this forum?

Re: Treatment off the internet

Mark Holmes — Mon, 24 Sep 2012 17:55:33 GMT

[quote user="J G Wray"]

What my father drew from this was the need to able to justify yourself, as a professional, with the best available information, at all times - just in case your patient really needs it. Oh and not to get exasperated.

[/quote]

What about the anaesthetist's other patients whom I presume are suffering neglect in his/her absence, unles they were so over run with anaesthetists they could justify one justifying himself ad infinitum

Re: Treatment off the internet

Evelyn Barbour-Hill — Mon, 24 Sep 2012 17:45:28 GMT

[quote user="J G Wray"]said something along the lines of "Madam, I cannot distil 5 years of university and thirty years of practice in a way which answers all these questions, we really need to get on..."[/quote]

Hey, I've said words to that effect on a number of occasions.

Re: Treatment off the internet

James Laidlaw — Mon, 24 Sep 2012 17:01:58 GMT

[quote user="J G Wray"]I find it baffling colleagues don't justify themselves and evidence it to clients.[/quote]

Who exactly don't justify themselves and their evidence? This is a fairly broad and damning generalisation to make... Any of your evidence there to back it up and justify it to your colleagues?

Re: Treatment off the internet

Arlo Guthrie — Mon, 24 Sep 2012 15:38:27 GMT

[quote user="J G Wray"]It is inferior to most, as has been pointed out, in the EBM scale.[/quote]

I think we're talking about different things here. I am talking about vetsurgeon.org as a source of information, the quality of which will vary. Some will be EBM of the highest order, other information will be anecdote from an unknown source, which is of the lowest order.

I would say that being able to tap into the collective memories of the members of this site makes it of the very highest order as a source. NOT that the information you will find here is always of the highest order.

Am I making sense?

Re: Treatment off the internet

J G Wray — Mon, 24 Sep 2012 15:26:05 GMT

[quote user="Arlo Guthrie"]Secondly, your implication is that sourcing information on here is somehow, I dunno, inferior. Forgive me JGW, but that is bollocks.[/quote]

Nice.

It is inferior to most, as has been pointed out, in the EBM scale.

Even RCVS has a point of view on sites like this in respect of CPD.

I think it would be weird to rely on treatment recommended on an internet discussion group like this and most contributors seem to feel they don't. What's not clear is how many tell their owners where they source information, or seem to feel it might be incumbent on them to do so, should they be asked.

Anecdote time, oh dear.

My father, now retired, was an anaesthetist, a human one and a friend of BMQ Weaver by the way. He told me once of a complaint made against a colleague who was dealing with a teenager who had stepped on a spiky fish thing somewhere in Kenya and had a gangrenous heel. The boys mother was grilling the colleague about how the boy would be treated prior to surgery, before signing consents. This was all taking some time and after the first hour of delay, with patient in agony, the colleague, exasperated, said something along the lines of "Madam, I cannot distil 5 years of university and thirty years of practice in a way which answers all these questions, we really need to get on..."

This resulted in a complaint, a visit from the manager and immediate, on the spot, suspension for the anaesthetist. The operation was cancelled resulting in further complaint. I do not know the outcome for the patient.

I find it baffling colleagues don't justify themselves and evidence it to clients.

JGW

Re: Treatment off the internet

James Laidlaw — Sat, 22 Sep 2012 09:08:15 GMT

Is anyone on here just blindly following one opinion from this site for a patient? Or given that we are ALL colleagues with the same degree do we do what I assume we do, and collate and assimilate the information and make informed decisions based on information available from our training and a variety of sources to ultimately benefit our patients? I've seen the worst of vets who never engage in case discussion or cpd of any kind. At least on here people are constantly questioning and refining their skills, and I doubt anyone is blindly following anecdote... We aren't idiots.

Re: Treatment off the internet

Mark Rowland — Fri, 21 Sep 2012 19:48:47 GMT

[quote user="alison howell"]

[quote user="Simon Neuhoff"]That said though there IS a certain amount of "peer review" [/quote]

Possibly the peer review on this site is actually better - for example, the MMR paper was published in the lancet - I doubt anyone would get away with that sort of thing on here! There are too many of us whereas usually only 2 'peers' would review a paper before publication in a peer-reviewed journal

Not saying peer-reviewed journals aren't good - they are probably more reliable than any other source - but many trials are very flawed or biased so you still need to take the findings with an enquiring and sceptical mind, as some weird and wacky things can always slip through...

[/quote]

I agree, some peer reviewed articles have quite a lot to answer for although most are fine. I really like this forum and see it as others do as a friendly(ish) information exchange like meeting up and chewing the fat with other vets at conferences.

Re: Treatment off the internet

vs0u — Fri, 21 Sep 2012 19:42:49 GMT

[quote user="Simon Neuhoff"]That said though there IS a certain amount of "peer review" [/quote]

Re: Treatment off the internet

Simon Neuhoff — Fri, 21 Sep 2012 18:47:48 GMT

[quote user="J G Wray"]

[quote user="Simon Neuhoff"]As to the OP - there is quite a difference in my mind between "I discussed it with a group of fellow professionals online" and "I read it on t'internet." [/quote]

OK, but do you make this distinction to yourself to justify your professional actions and do you make this distinction to clients to justify your professional actions? Are you so sure your professional evaluation of the information and treatment derived from vetsurgeon.org is what your clients want and need? Do you tell them if you use the internet, an unregulated area without standards to influence your decision? Would you be happy ( would VDS be happy) if it came to pass you had to justify yourself to a third party and you had only vetsurgeon.org to back you? Your traiinng and experience is never a shield to complaint and only one factor in mitigation of your position when in the spotlight.

If so, thenvetsurgeon.org clinical discussions and the treatment of patients determined should be lauded.

If not, then where is the info found on here in the pantheon of justifications for treatments?

JGW

[/quote]

Yes I make a distinction between plain ol' google, online professional colleague's advice, online specialist advice, textbooks, peer reviewed papers etc - as per EBM. I then make the best judgement I can based on that info that I have, and I stand by that. I am not foolish enough to take stuff here from a regular vet as gospel. That said though there IS a certain amount of "peer review" as when vets do things a little out of the ordinary others do tend to question this. Furthermore this is an online "community" - I have a pretty good idea of whose advice I can trust and whose I discard - and I always add a good dollop of salt.

As for justifying myself - I am a veterinarian and a professional - like most on here. It is my call regardless of the source of the advice and I will be judged and am "happy" to be judged as I would in any situation. Consulting an out of date textbook is just as fraught with potential problems!

Re: Treatment off the internet

Anthony Todd — Fri, 21 Sep 2012 17:42:43 GMT

[quote user="alison howell"]I don't see what is wrong with using a variety of sources, deciding what is the most reliable[/quote]

I'd rather be told by my colleagues, or on here, that something works than have a peer reviewed paper "proving" that it does.

[sponsored by the drug manufacturer....]

Re: Treatment off the internet

vs0u — Fri, 21 Sep 2012 17:35:34 GMT

Sometimes this forum may be the only of getting a certain type of answer - for example a while ago I posted a picture of a dog's mutant toe nail on here - not something I had come across before during 6 years in practice. I said to the client ' I don't know what is wrong with your dog, I am going to post a photo of it on a veterinary forum and see if anyone has any ideas' The client was pleased with this approach. Within a couple of days I had several opinions from people more experienced and also a pathologist, (not all of whom agreed but there was a clear consensus). I would have had to scour a lot of peer reviewed journals/text books to get the same info! The opinions of those on the site were a definite aid in deciding what to do - obviously there were many other considerations too.

I do also google things sometimes - for example when a client was bringing in a dog that they thought had shar pei syndrome - at least I then had an idea of what this condition was before seeing the dog although obviously I would use a more reliable source than google for further info.

Sometimes it's good to run things by colleagues to check you haven't missed anything obvious, for unusual cases, for moral support. Text books aren't so good for these...

I don't see what is wrong with using a variety of sources, deciding what is the most reliable. Better than thinking you know it all already!

Re: Treatment off the internet

Mark Holmes — Fri, 21 Sep 2012 17:04:59 GMT

Clearly a slow day at Ivory Tower Veterinary Clinic.

Why this "Vetsurgeon.org" is any different to a case discussion in a practice meeting I have no idea. The only difference is there is many more brains some of which are educated.

Re: Treatment off the internet

Bob Russell — Fri, 21 Sep 2012 16:57:16 GMT

Clearly Mr Wray feels this site is leading vets astray. It is a fun community where relaxed but sometimes opinionated discussion goes on. It has had quite an important place in supporting an occasional vet in difficulties. It helps some of us by confirming we are not on our own.

Sometimes I want advice, usually reassurance that I have not missed anything obvious. This is like having a group of vets to bounce ideas off over coffee!

I value the input of the specialists on the site but generally for specific cases I have referral specialists at the end of a phone when required. Vetsurgeon supplements but does not replace other CPD.

I don't use the site to diagnose my cases so treatment (perhaps with the exception of some exotics) is determined by me, not the internet and would expect others feel the same!

Long may it continue!

Re: Treatment off the internet

Malcolm Ness — Fri, 21 Sep 2012 16:18:29 GMT

You aren't trying to tell me that Dr Google gets it wrong sometimes???

Surely not!

Re: Treatment off the internet

David Mills — Fri, 21 Sep 2012 16:15:11 GMT

[quote user="Arlo Guthrie"]

Is this not a case of stating the plainly obvious, or am I missing something here!

[/quote]

I think you may be. Far from it for me to make Mr Wray's case, but it's this:

[quote user="J G Wray"]

If not, then where is the info found on here in the pantheon of justifications for treatments?

[/quote]

The answer on an EBM scheme for most of the advice on here (not that of specialists or those with further qualifications) would be 'lower than anecdote' i.e. below even the lowest current EBM scoring evidence. Essentially one is taking advice off people of whose providence we have absolutely no idea. There is a huge amount of difference between 'I saw one like this once' and 'someone off an internet forum said to do this'.

[quote user="Arlo Guthrie"]

I don't know why you are singling out vetsurgeon.org, and not applying your line of thinking to EVERY unregulated source of information that veterinary surgeons glean knowledge from?

[/quote]

Oh, come, come, this place is unique. Only vets or vet industry people are supposed to be here. You can't be an exclusive forum then compare yourself to the internet at large. Therefore, by making it for vets (and CPD-qualifying) there is a certain - or should be - ethos of professionalism and integrity. The obvious comparator is VIN, which is awash with experts and therefore rises above vetsurgeon in the EBM scheme. Now vetsurgeon isn't VIN and doesn't try to be, but please, a bit of perspective about what it is cf rest of the internet.

Re: Treatment off the internet

Arlo Guthrie — Fri, 21 Sep 2012 16:03:54 GMT

[quote user="J G Wray"]Are you so sure your professional evaluation of the information and treatment derived from vetsurgeon.org is what your clients want and need? Do you tell them if you use the internet, an unregulated area without standards to influence your decision? Would you be happy ( would VDS be happy) if it came to pass you had to justify yourself to a third party and you had only vetsurgeon.org to back you?[/quote]

I don't know why you are singling out vetsurgeon.org, and not applying your line of thinking to EVERY unregulated source of information that veterinary surgeons glean knowledge from?

Do you, JGW, inform your clients whenever you seek an opinion from a colleague, or when you read something about their pet's condition in a magazine that is not peer-reviewed. Do you apologise to your clients for looking for further information elsewhere on the internet, beyond vetsurgeon.org? Do you flog yourself on the back with a birch if you read some drug company propaganda/literature about a condition you are treating?

I presume not. I presume like everyone else you assimilate information from a variety of different sources, very few of which would be classed as the highest grade of double-blind, randomised, placebo-controlled, peer reviewed, certified CPD source. I presume you make a judgement about the quality of ALL information you are presented with, and decide its value accordingly.

VetSurgeon.org is no different. There are great benefits in pooling knowledge, sharing experiences etc. But OF COURSE you need to use it with caution.

Is this not a case of stating the plainly obvious, or am I missing something here!

Re: Treatment off the internet

J G Wray — Fri, 21 Sep 2012 15:48:43 GMT

[quote user="Simon Neuhoff"]As to the OP - there is quite a difference in my mind between "I discussed it with a group of fellow professionals online" and "I read it on t'internet." [/quote]

If so, thenvetsurgeon.org clinical discussions and the treatment of patients determined should be lauded.

If not, then where is the info found on here in the pantheon of justifications for treatments?

JGW

Re: Treatment off the internet

Simon Neuhoff — Fri, 21 Sep 2012 15:02:43 GMT

[quote user="David Mills"]

[quote user="Arlo Guthrie"]

David, I don't personally think there is a problem with veracity. Online communities such as this only mirror offline communities.

...

So the point is not about the veracity of information, it is about your ability to distinguish between good quality information and poor quality information; something you are all trained to do (no?).

[/quote]

OK, I didn't mean veracity in that someone is deliberately lying, but more in the sense of someone's ill-informed opinion or skewed view of some matter, clinical or otherwise. Problem is - as with any face-to-face interaction with colleagues, I admit - with knowing the foundations of such. With a textbook you can check the references and see if the authors stand up to scrutiny, similarly at CPD you can grill the expert on the evidence. Online, however. it is eminently more difficult. You don't know the person at all, never worked with them etc., and have no idea of their prejudices or influences - it is really, really, difficult to rationally follow such advice. Its use begins and ends with pointing at a direction you may not have thought of. In this way, the veracity of the opinion is key - and it can be impossible (especially if you're asking a question about something you're not sure of) to distinguish with any certainty what is wheat and what is chaff.

This doesn't maintain if they have further qualifications: these to some extent lends a large objective rubber-stamp on what's being said is being said with good sound reason e.g. a cert holder or a specialist - this is what this forum is great for (along with being a barometer of prevailing views), along with throwing out rare cases for observations. Personally, I'm uninterested in anecdotal-based opinions on common conditions where better evidence exists.

[quote user="Arlo Guthrie"]

David, your post suggests you think you are the only person to question what you read; that others are slavishly following forthright opinions expressed on this site. I think that you don't give your peers sufficient credit, and people are more enquiring than you think!

[/quote]

I don't think it does, that wasn't the intention at any rate. There are reams of stuff on clinicians acquiring knowledge, however, and the number one things apart from 'that worked last time' is a personal recommendation from someone else. (CPD is pretty useless overall (at least for medics) with only about 20% of new knowledge ever being utilised.) Therefore this forum has its dangers especially where time is short and you don't have time to read further or assess the info. I'm sure most people do find time, but this is essentially unquantifiable, and people don't always do what they think they do. I just think care is required - it's why Mr Wray's question is a very pertinent one. It is no surprise that one of our great anecdotalists decided, spectacularly unsuccessfully given the subsequent rate of posting, attempted to denigrate the poser.

[/quote]

Broadly in agreement David. I have been a locum off an on over the years and worked with a large number of vets in different parts of the country. Many of the vets I have worked with have been up to date, conscientous and diligent in pursuing a high level of care for their patient and their client but not all! I have been repeatedly struck by how often vets believ in the wierdest, wackiest stuff with no evidence base whatsoever. So I have what I think is a healthy suspicion of fellow GP vets opinions - whether it be here or in real life. I am prepared to listen to their views and try to learn from them where appropriate. I have in fact learned quite a lot from Vetsurgeon but I have also been disappointed by my fellow colleaugues on a number of occasions.

As to the OP - there is quite a difference in my mind between "I discussed it with a group of fellow professionals online" and "I read it on t'internet."

Re: Treatment off the internet

David Mills — Fri, 21 Sep 2012 13:36:05 GMT

[quote user="Arlo Guthrie"]

David, I don't personally think there is a problem with veracity. Online communities such as this only mirror offline communities.

...

[/quote]

[quote user="Arlo Guthrie"]

[/quote]

Re: Treatment off the internet

Clive Ansell — Fri, 21 Sep 2012 12:38:23 GMT

Complete nonsense and BS.

We don't "treat off the internet" , we treat based on 5+ years of university training, plus Y years of clinical experience, with some possible input from dialogue with professional colleagues on a closed Internet forum. A world of difference.