Friday, May 21, 2010

Let the Facts Lead You to the Conclusion

One of the duties of a judicial law clerk is to help the Judge write his or her decisions. To do this the law clerk will review and summarize the facts of the case, research existing law in similar cases, write a draft of the decision and present those to the Judge for discusion, editing and publication.

When my husband Bill was a Law Clerk, he was given his first assignment to research case law for a recently finished trial. Not knowing how to even start, he asked the Judge who should win. The Judge gave Bill the advise he follows to this day as a Judge himself; "Let the facts lead you to the conclusion not the other way around." It sounds obvious, but sadly, it is not unusual for some judges to have a pre-conceived idea of what the final outcome should be and look for facts that lead to the decision they want to make rather than letting the facts lead to the conclusion they should make. By promoting their own ideas of how things should be rather than deciding the case on its merits, the Judge does a disservice to justice.

Every day, we Veterinarians find ourselves in a similar position. In my previous post I wrote how we are like Detectives sorting though the facts of a case. Just as it is important for the Judge to let the facts lead them to a conclusion, it is important for us to do the same. We develop our differentials list(the list of possible causes) based on the patient's medical history and our exam findings. Additional testing such as blood & urine tests, x-rays and/or ultrasound help us put the differentials higher or lower on the list. This, in effect, leads us to a conclusion, or in our case, a Diagnosis.

If we presume to judge a case by choosing only to use the history, exam or test findings that support our "diagnosis", we are not doing justice to our clients and patients. We need to use all of the information and let it lead us to wherever the diagnosis lies.

Why might we even choose to pre-diagnose and use the tests to lead us to what we want to find? There are many reasons. Perhaps because it is the quickest or easiest way to finish the case or maybe because we think we are doing our patient or client a favor by providing a quick answer, or saving them money, or sparing them from a diagnosis they don't want to hear. Ultimately, we are doing them a disservice by providing the wrong treatment and delaying or missing the opportunity to provide the correct treatment.

I'd like to share Bubba's story with you.

I met Bubba and his owners on April 16. His owners were concerned about his recent weight loss. Also, they observed that some of the urine clumps in the cat litter box were larger than they were in the past, and that one of the cats was vomiting every other week.

During my exam, I found that Bubba had lost almost 1 1/2 lb since last August, his right kidney was smaller than the left and he had a tooth with a resorptive lesion (similar to a human tooth cavity in it's effects on the tooth, but not due to the same cause).

I suspected that kidney or thyroid disease, diabetes, intestinal disease, pancreatitis or cancer were possible causes for his symptoms. I ordered initial testing including blood & urine tests and x-rays to give me additional information.

Results showed that Bubba had degenerative changes in his kidneys. His thyroid hormone level suggested that he had an overactive thyroid. Because the test results fit 2 of the diseases I suspected, I could make a case for starting treatment. However, to do so, I would have had to ignore other test findings and history. I needed to let the facts lead me to a conclusion.

So, I ordered additional testing. Abdominal Ultrasound and a recheck of thyroid hormone levels was performed a few days later. Bubba's weight continued to decline and his appetite was lower than normal. Ultrasound showed that there were irregularities in his kidneys, as well as changes in his intestines which can be seen with an overactive thryoid or intestinal disease. Again, the results matched diseases on my differentials list but given the fact that the changes were mild, I decided to set aside the information and re-test.

Repeat thyroid hormone testing was normal...confirming that I would have done a disservice to my patient if I had started treatment based on fitting the facts to a quick and easy "answer".

All of the facts lead me to conclude that Bubba did have chronic kidney disease and that he needed to start a special diet. However, when searching for the cause of decreased appetite and weight loss, the facts were not leading me to a conclusion that was on my list so I had to go back to the start.

Up to this point, I had focused on weight loss due to several causes, and had put taking care of Bubba's teeth on hold. After all, it was only 1 bad tooth and lots of cats show no ill effects from a single bad tooth. But the fact is, a painful tooth CAN cause decreased appetite, and decreased appetite CAN lead to weight loss, and intense pain CAN cause vomiting. As skeptical as I was that this one tooth was the source of the remaining problems, it was time to address his dental disease. Bubba needed an oral exam, dental x-rays and dental work. I had to let the facts lead me to a conclusion.

My surgery technician completed her dental probes and cleaning and was the first to see Bubba's x-rays. I was stunned to see the extent of his dental disease. It wasn't just the one tooth with a cavity-like hole in the enamel, there was also a loose tooth and both lower canines had roots that were being eroded away and were surrounded by large areas of abnormal jaw bone. Most likely I was seeing osteomyeleitis, bone infection, but was concerned about the possibility of bone cancer. My technician cleaned Bubba's teeth, I treated the tooth with the resoprtive lesion, I removed the loose tooth and the remaining parts of the lower canine teeth, and took biopsy samples from the diseased bone. I treated Bubba with antibiotic and painkillers during the dental procedure and he went home.

Bubba responded well. He ate. He gained weight. At his recheck earlier this week, I could see that the extraction sites were healing nicely.

Bubba is fortunate to have 2 very loving and committed owners who allowed me to use the advice given to my husband by a very wise mentor. Let the facts lead you to a conclusion. Had I stopped when I had enough facts to fit my initial suspicions, I would have been doing Bubba a great disservice and would have treated medical problems he didn't have while failing to treat him for the painful medical problem he did have.

This is a photo of Bubba's normal looking lower canine teeth

This is the x-ray of Bubba's lower canine teeth (what's left of them)

Normal x-ray appearance of lower canine teeth

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