While Pragmatic Veterinary Medicine is getting a lot of attention these days, the language got its start 30 years ago in a book entitled “The Encyclopedia of Pragmatic Medicine.” Since then, however, we have never again seen the words “pragmatic” and “medicine” combined together.
What Is Pragmatic Veterinary Medicine?
Pragmatic veterinary medicine is defined as a cost-conscientious and practical approach to medicine. To a veterinary student studying theory, this concept may be confusing. Learned theory may seem disconnected from practiced reality when the decision tree becomes muddled with cost, professional and personal beliefs/experience, and clients ultimately making final decisions. If you believe that you have been taught the “gold standard way,” an inability to practice medicine according to the “gold standard” may cause moral confusion, fear of litigation, fear of negative client reviews, and concern about being judged by industry professionals.
However, there is no gold standard way to practice medicine; there is a “standard-of-care”, although this definition is a moving target. As a legal term, standard-of-care is defined by past and future court cases and thus is a definition that can and will change. The currently accepted definition is that which a minimally competent physician in the same field would do under similar circumstances.
The term Value Based Care is an emerging concept in both human and veterinary medicine. The goal of value-based care is to achieve the best patient outcomes at the lowest cost and recognizes that in order to reach this goal, 1 or more outcomes must be improved without raising cost, or, cost must be decreased without sacrificing outcomes. Cost should include all costs, outcomes are evaluated multidimensionally, and value is considered in the long-term and not the short-term.1
Pragmatic veterinary medicine aims to practice value based care with outcomes that are measured on more than just life and death.
The Pragmatic Veterinary Medicine Approach
The simplest and most cost-effective way to practice pragmatic veterinary medicine is to take full advantage of the:
- Physical examination
This is the free and available data to point us in the proper direction.
Signalment is the age, breed, sex, and neuter status of the patient. Beyond the obvious, that a pyometra is not a good differential for a degenerative left shift in a neutered male dog, understanding the typical signalment for various diseases helps get our thoughts moving.
The history is not just what the owner says, nor is it just what the owner or previous healthcare professionals thought. To evaluate the history requires reviewing all prior test results, all prior treatments and their effect, and the prior diagnoses to determine what was confirmed and what was assumed.
Next, perform a complete and thorough physical examination following your own consistent approach and do not skip retinal and rectal examinations. The data collected is free! Compare the results to previous examinations and look for changes or trends. The veterinarian may note changes in hair coat, body condition, and weight before the owner. Write your exam notes immediately (even in rough chicken scratch) to spur your memory later when you sit down to type. Complete and thorough medical records are not just mandated by state licensing boards but are also required in the practice of pragmatic medicine. When information is incomplete or inaccurate, there is an increased risk of assumptions, which might lead down to wrong path.
“The best decisions are made when the clinician evaluates all of the data available to them: the signalment, history, physical examination findings, and the individual interpretation of the test results relative to each patient.” – Dr. Heather Kvitko-White
Pragmatic Veterinary Medicine Balances Cost and Value
Cost conscientious does not necessarily mean cheapest nor does it mean cheap. Short-term cost saving could result in more cost in the future and the most cost conscientious decision is not always the cheapest.
Value is not equivalent to cost savings. Value = costs + outcome. Costs include all costs and long-term outcome. This is a different way of thinking when we are so accustomed to looking at research defined by just one outcome, i.e., survival.
How To Lower Cost Without Compromising Value
Pragmatic veterinary medicine is not one specific idea or approach. Pragmatic veterinary medicine is a way of thinking about the pet, the disease process, the treatment options, cost, and impact to the home and family life.
One of the simplest things you can do to practice pragmatic veterinary medicine is to become very familiar with your reference lab. Familiarize yourself with available panel options and the cost of each. Whenever possible, particularly if the cost is the same (or even less), collect more diagnostic data than you anticipate you might need. Avoid mini-panels or incomplete chemistries, most especially in the sick patient. A cost-saving tip: many laboratories located at University Teaching Hospitals offer a wide variety of diagnostic tests with lower cost and rapid turn-around-time compared to the larger private laboratories.
Another way to practice pragmatic veterinary medicine is to bring in a veterinary specialist as part of an integrated practice unit (IPU). An IPU is a team of people working collaboratively for the common goal of maximizing the patient’s value-based outcome. In veterinary medicine, the IPU typically consists of the veterinarian, the pet owner/caretaker, and possibly a specialist veterinarian or veterinarians. When a specialist is brought in, outcomes typically improve. In a study published in 2016 dogs with congestive heart failure lived ~75% longer when treated collaboratively compared to the GP alone and resulted in a nearly 25% increase in revenue for the primary veterinarian.2
Just like the laboratory, the specialists you use are part of your toolbox. Shop around and compare. Find the specialist that instills comfort and confidence in you and your clients. Speak to the specialist frequently and ask advice. Read their paperwork to see if they are doing something differently and follow up if you have any questions. As with any relationship, communication is key. Let the specialist know your expectations in advance and make sure to provide candid feedback if unsatisfied. Reward the positive experience by sending your referrals.
Finally, keep current on emerging trends and research. If nothing else, newly published revelations often contain cost-saving gems. For instance the ISCAID provides open-access recommendations for the management and workup of lower urinary tract infections. With increased recognition of subclinical bacteriuria, the guidelines for when to perform a urine culture and the duration of antibiotic therapy have changed significantly.3 While change often is difficult, pragmatic veterinarians maintain the ability to embrace cost-saving updates as part of the “standard of care.”
In conclusion, pragmatic veterinary medicine is cost-conscientious, practical, adaptable, and collaborative. It considers cost to the extent that it adds to or detracts from ultimate value. Pragmatic veterinary medicine may be different from the approach that you once learned, which is OK. Pragmatic veterinary medicine is still excellent medicine.
- Pantaleon L. Why Measuring Outcomes is Important in Health Care. JVIM. 19 February 2019.
- Lefbom, BK and Peckens, NK. Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for attending primary care veterinarians. JAVMA. July 2016; 249 (1).
- Weese, JS et al. International Society for Companion Animal Infectious Diseases guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats. Vet J. May20