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Veterinarians get $'s for Green Sheets

This is Mikey, aka Michel’s Magic. He is a 16 yo Haflinger I have had since he was 3yo. He has worked as a Therapeutic Pony in my former nonprofit program, The Happy Horse Farm , and helped countless children heal their grief issues as well as learn coping skills with anxiety, depression & ADHD. He became my dressage partner at age 6 & has won multiple awards. He was working on his Piaffe and Passage at the he became ill. The canter has always been more difficult for him. My trainer became concerned when he began tripping at the canter & recommended we call our veterinarian who began the process of diagnosis. Thank you again and your team for all the work you are doing in regard to diagnosing and treating EPM. and I am forever grateful to my team.

Veterinarians were encouraged by Dr. Michael Riegger* (DVM Newsmagazine, Oct. 2012) to stop practicing one-size-fits-all medicine. We couldn’t agree more when it comes to horses with clinical signs of musculoskeletal disease. These horses are treated effectively when managed on a case-by-case basis. The key to managing these cases is testing and examination. After effective therapy, a proactive approach keeps the post-treatment horse on the right track.

The “change a belief into evidence” strategy proposed by Dr. Riegger is “based on the wealth of information and its dissemination based upon evidence-based medicine”. He says that evidence is lacking to support many of the clinical activities and common practices in veterinary medicine today and proposes his solution to provide “evidence”. “It’s also a message to acedemics, to people who get all their veterinary medical information from the internet, and to veterinary examining boards trying to establish norms for the so-called ‘local standards of practice’, which are used to pass judgment on veterinarians who must defend their actions before these state boards”.

He suggests the veterinarian can track repeating cases (various examples such as seizures or ear infections are offered) on “green sheets” that track data from individual cases on a sheet of green paper (or Excel). He gives an example of 10 cases, that he tracked by green sheets. Ten animals received carprofen for pain management—“a few of our patients experienced liver problems while receiving the medication”– and the adverse reaction was reported to the manufacturer. It is suggested that the “few cases” among the 10 was proof that carprofen can induce liver damage and checking liver enzymes would be prudent.

In essence, Dr. Riegger proposes taking the problem list (usually in the first pages of the patient chart) and enhancing it with a treatment list on a sheet of green paper. He indicates that assessing the situation individually, patient by patient—“there is no one-size-fits-all approach to medicine”—is a means to provide the best possible care to the patient. He is advocating a series of anecdotal reports to provide evidence upon which to change one’s treatment decisions.

Information is always good, but we question that a series of anecdotal reports from a single practice, no matter how plentiful, are evidence. Adding up numerous observations may suggest a hypothesis that could be tested using the scientific method. The evidence gathered by a scientific study is what changes a belief into practice. The scientific method is our choice for evidence. A hypothesis is stated and then that hypothesis is tested. The study that tests the hypothesis involves controls and an analysis of confounding factors. We value anecdotal information and we test interesting hypotheses that result from the observations using the scientific method.

Field data enhances a scientific study. It isn’t enough that a controlled study shows a direct cause-and-effect. In practice it is necessary to test all sorts of confounding factors. These factors could alter the outcome of the experiment and result in a false interpretation of the results.

Sometimes field data yield unanticipated results that were not observed in the controlled study. One only has to read about Viagra’s rise to fame to know this is true.

Our information is based on controlled animals studies for which we develop models. Studies based on our models generated interpretable data for diagnostics and treatment. Treatment expectations differ between the early case and a chronically infected horse that has been treated many times with ineffective products. Treatment requires understanding of the pathogenesis of disease and that is done through testing. Effectively treated horses need follow up diagnostics and neurological exams after the end of treatment. The proactive management of the neurologic horse is more than a green sheet, it is evidence-based medicine.

We don’t discount the value of your green sheets. If you send us your green sheet on an unresolved case of EPM or PNE we will help you with diagnosis and treatment. If the horse fits the enrollment into our study we can help you if it is financially difficult to satisfy the entrance criteria. Call to find out the possible financial programs we have to help with diagnosis and treatment.

*Dr. Michael Riegger DVM, DABVP passed October 9, 2021 of a final sudden illness. Northwest Animal Clinic and Hospital posted this link.


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