Preface

"What was it like when you were in vet school?"

It is a simple question that I am often asked by my students. A simple question with no easy answer.

The vet school experience to discover our own personal and professional identities encapsulates so many thoughts and feels, so many unique milestones and setbacks.

It is a journey that I would do all over again yet one that I frequently fast-forward when taking a walk down memory lane because mine, like many, was riddled with insecurity and the fear of never being "enough."

No one in my graduating class knew what constituted "enough," yet the one thing we collectively convinced ourselves of, on Commencement Day, is that whatever "enough" was, we did not have it!

In those days, we lived in perpetual fear of being labeled substandard. We compensated by committing facts to memory. We learned through positive punishment which answers to questions were "correct" and therefore worthy of accolades. We steered clear of those that spelled defeat.

So it was that most of my clinical year was spent reciting diagnostic plans like recipes. In truth, I did not always understand the purpose of each or how to interpret them. I simply knew how to play the game to get the answer "right."

What I learned in the years that followed was that the practice of medicine is not a game and that "why?" often matters more than "what?" But in the moment, the "what?" took precedence and at times clouded my understanding of clinical casework during my early years as a "baby vet."

When I close my eyes to reflect upon my journey through veterinary medicine, I can still place myself as a timid student in clinical year.

The year was 2008.

It was a few months shy of graduation and I was well into week two of my Emergency/Critical Care rotation at Cornell University Hospital for Animals, standing in the adrenaline-infused corridor that led to the ICU.

I had just triaged my 26th case in less than 24?hours over a holiday weekend.

I was running on no sleep and no food.

The case was a 12-year-old female spayed domestic short-haired cat that presented for acute vomiting. The patient was stable enough to sit in its carrier and watch me with trepidation as I summarized her history for the benefit of the attending resident.

I did as I was trained to do. I led with the patient's signalment, followed by a timeline of their chief complaint:

• three-day history of "ADR"
• two-day history of hyporexia
• four emetic episodes overnight
• lethargic all morning

I tacked on other pieces of data that seemed relevant to the case:

• indoor-only
• no other pets in household
• no pre-existing conditions
• no known access to or ingestion of toxins
• no current medications, including supplements and preventatives.

Keep in mind that I had yet to perform a physical exam. If you asked me today what my exam findings were for that patient on that specific day, I could not tell you. I cannot recall. What I do remember, as if it were yesterday, was what the attending clinician asked of me in follow-up:

"What is your diagnostic plan?"

I remember the question because, back in those days, my response was programmed to recite the same thing, each time, every time, regardless of whether the case presentation was diarrheic dog or a diabetic cat.

My response was always:

QATS, Blood gas analysis, CBC/Chem/UA, chest rads, and abdominal ultrasound.

I might have added in FeLV/FIV serology as a bonus for a cat or HW/L/E/A for a dog. Maybe even a thyroid panel for good measure. But the foundational plan was always the same. If nothing else, I had learned to be consistent in my test selection.

I was far less certain of the rationale - that is, why each test was vital to the patient's workup.

As a student, I was rarely asked to contemplate the "why?," as in:

• Why should each test be run?
• Why is each diagnostic test of value?
• Why might each step of the diagnostic plan be efficacious?
• Why this test and not another?
• Why run tests simultaneously rather than sequentially?
• Why was there value in broadening the data set?

It was always just assumed in the Teaching Hospital that we could ask the client for the sun, the moon, and the stars, so why not? And if for some reason our hands were tied, then we were taught that the client was not allowing us to be thorough.

It never occurred to us, as students, that we could choose to prioritize some test(s) over others - and with good reason.

What we were not taught then but needed more than ever when we graduated was the skill of clinical reasoning. Clinical reasoning requires health-care providers to be detectives. We must consider for every patient the odds that disease "x" is most likely and balance these odds against clinical uncertainties. We must problem-solve, strategize, and customize to provide patient-specific care. We must acquire and analyze data that is specific to the patient's problem list to accurately initiate, evaluate, and adapt case management as patient-specific needs evolve.

Clinical reasoning is inherently tied to critical thinking. Both are dynamic processes. They do not begin and end with diagnosis. They require an intimate understanding of contributing inputs and patient-specific factors.

To become effective at clinical reasoning, clinicians must gather and compare key pieces of data that are obtained through deliberate history-taking. Physical examination findings provide an additional layer of evidence for clinicians to interpret and formulate hypotheses about which diagnoses are most consistent with case presentation.

To test hypotheses, we must perform diagnostic tests. Which test to run is a critical component of the detective work that is required of us in veterinary practice yet the answer to this question is not inherently obvious.

The Veterinarian's Oath tasks us to act as stewards of the animal kingdom. This ethical agreement requires veterinarians to prioritize patient welfare and the prevention of disease above all other external influences, including finances. On paper, these tasks are self-explanatory and clear-cut. However, patients more often present in shades of gray that threaten our understanding of how to deliver high-quality, gold standard medicine, particularly when patient outcomes may be contingent upon cost.

What do we do when we can't do it all? What do we do when we can't run every test? What happens when our clients experience financial constraints? What happens when we lack the diagnostic equipment to proceed? What happens if we lack the client's consent?

Ryane Englar the Student was not prepared to face this clinical reality.

The student in me was not trained to brainstorm alternatives.

Instead, the student in me was trained to see alternative approaches as "lesser" or "substandard" in the same way that I was taught to view myself when I did not have all the answers.

The student in me was trained to recommend the gold standard for every patient with the understanding that this approach always provides the greatest diagnostic accuracy. In a world of ideals, the gold standard was always possible.

However, as scientific advances revolutionize the number of diagnostic tests that are available to our client, the gold standard is not always feasible. What happens when the price of treatment exceeds the client's ability or willingness to afford the gold standard? Are we pricing people out of pet ownership?

Beyond the question of affordability, who determines standard of care? Where is the evidence to support it?

Is a one-size-fits-all approach truly best? Or should the "best" approach be determined by the situation, the context, the patient, and the client?

It is vital that we offer our clients options. It is vital that we consider the whole patient. It is vital that we investigate clinical signs and offer a comprehensive approach to diagnostic medicine so that we find permanent solutions rather than Band-Aid approaches that offer temporary fixes.

At the same time, what constitutes comprehensive and why do certain tests fall under that umbrella? Are we testing out of the desire for completeness, to cover all bases for the good of the patient? Or are we testing because we are expected to?

If we are testing because we are expected to, then who is it that determines the standards? Who sets the bar? Are we testing out of peer pressure or are we testing to cover our bases in the event of litigation? If that is the case, then is testing appropriate? Is it right for the patient or right for our reputation? Does it matter? Should it matter?

As is typical of veterinary practice, there are no easy answers. As clinicians, we are left to determine for ourselves what constitutes "best practices." The challenge to understand "best practices" has recently precipitated discussion within our profession about a shift away from the "gold standard" toward "spectrum of care." This term implies...