The Problem with Problem-Oriented Medicine
By
Myrna Milani, BS, DVM
Perhaps no concept poses more of a challenge to the creation of a
meaningful relationship between practitioner, client, and animal than the
problem-oriented approach.
This isn't to say that the concept of reducing an animal to a problem
doesn't have its advantages. As the ever- increasing number of specialties in
the biological and medical sciences attests, even the most primitive life form
may be amazingly complex; the more we can reduce an animal to a collection of
ever smaller parts, the more details we can know about each one of these.
Similarly, it seems that the more we know about various diseases and
injuries, the more we need to know; focusing strictly on those problems
permits us to eliminate the many variables that might distract or confuse us.
The process also enables researchers to compare data collected from animals
with a certain problem with data collected by their colleagues worldwide,
further expanding our knowledge of and ability to treat that particular
condition. And, finally, the approach gives rise to a uniform teaching method.
But while the problem-oriented approach greatly facilitates the
accumulation and exchange of data, it can create its own problems for
practitioners.
For one thing, the probability that a veterinarian will walk into an
examination room or stall and encounter just an inflamed bladder, edematous
lung, or comminuted fracture of the femur approaches nil.
Far more likely than not, that problem will come incorporated in an animal
which belongs to a person. And unless we take both of them as well as the
problem into account from the beginning, the treatment process can become much
more complicated very quickly.
Not surprisingly, few owners think of their animals as a body part,
disease, or some other problem any more than they view themselves that way.
Consequently, when Ms. Bach hears Dr Problem-Oriented, the new veterinarian
at the Maple Grove Animal Clinic, refer to her pet, Darby, as " The
broken leg in the third ward," this causes all kinds of negative thoughts
to cascade through her mind.
Granted, Dr P-O might easily dismiss these as inconsequential saying,
" My job as a veterinarian is to repair that fracture to the best of my
ability and I did a first-rate job. Once Ms. Bach sees that, I'm sure she'll
agree." Maybe she will, but maybe not. Perhaps, given her pet's history
and her relationship with him, Ms. Bach might view the clinician's
problem-oriented approach as sloppy and lazy at best, and down right negligent
at worst.
Consider this worst case scenario:
" Because the wound at the fracture site was contaminated, I want you
to give these antibiotics twice a day until they're all gone, plus this
pain-killer," Dr P-O confidently instructs Ms. Bach.
" No," replies the owner as she reads the label on the container
of antibiotics the veterinarian handed her. " This is the same drug that
made Darby violently ill last year."
The embarrassed clinician quickly scans the record and, sure enough,
discovers a notation made by a colleague regarding the animal's adverse
reaction to that particular medication fourteen months previously.
" Ah, yes, I see," says Dr P-O, back-tracking furiously. "
I'll get you something else."
Unfortunately, the veterinarian's failure to acknowledge Darby as a
complete being coupled with her lack of knowledge of his non-fracture-related
history have dealt a major blow to Ms. Bach's faith in Dr P-O. Because of
this, from now on the client will either outwardly or inwardly question
everything the veterinarian says or does.
" Oh, and make sure any medication is in liquid form," she calls
out to the retreating practitioner. " I can't get pills into Darby."
When Dr P-O returns with the proper medication, she bids farewell to owner
and pet saying, " Be sure to keep Darby quiet until that leg heals."
Rather than leaving as the veterinarian had hoped, the client asks, "
How will Darby's leg affect his behavior? Can he go up and down stairs or jump
into the car? If not, should I carry him? If so, how should I hold him? Will
it hurt him? If it won't hurt him because of the pain medication, will the
medication make him drowsy?
Some pain medication my neighbor gave his dog made the animal so woozy he
could barely walk. I work all day and could never leave Darby in that shape.
Otherwise he might fall off the couch or down the stairs when he hears the
school bus because he goes crazy when he hears it. What can I do to prevent
that?"
Once Ms. Bach finally leaves, a frustrated and defeated Dr P-O sags against
the wall, all thoughts of that brilliantly repaired fracture long gone from
her mind.
In this situation, we can see how the veterinarian's problem-oriented
approach carried little weight with the owner. This isn't to say that Ms. Bach
doesn't a ppreciate the knowledge and skill that went into the repair of her
pet's fractured leg.
However, for many owners the problem as defined by the veterinarian to some
extent serves only as a small fraction of a far bigger picture.
Dr P-O, at most, may only see Ms. Bach and Darby weekly, if that, unless
other medical problems arise. However, until Darby returns to his pre-fracture
self (if he ever does), Ms. Bach's life might be totally altered.
A lack of solid veterinary support regarding how to best deal with all of
these changes could undermine the animal's recovery on two fronts. First, the
owner might not be able to properly implement the aftercare necessary. Second,
the failure to do this could lead to owner guilt and frustration which could
negatively affect the owner's relationship with the animal as well as the
veterinarian.
Although few question the convenience of the problem -oriented approach, it
overlooks one glaring reality practitioners must confront everyday: animals
aren't problems.
They are a unified collection of inextricably entwined synergistic elements
evolved to maintain homeostasis and living in an ever-changing human-mediated
physical and behavioral/emotional environment. The sooner we recognize this in
the treatment process, the better for patient, client, and practitioner.
©2002 Myrna M. Milani, DVM Telephone: 603-542-7227 - e-mail: mm@mmilani.com
HC 60, Box 40 - Charlestown, NH - 03603
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