The 3-step mantra ingrained into my brain during my residency in medical oncology was to “name it, stage it, and treat it.”
The philosophy is simple: First you must identify the disease process you’re dealing with (name it). Then you search for where in the body you can find evidence of the disease (stage it). Then you decide on the most appropriate treatment regimen (treat it).
I would estimate that 95% of the cases I managed during those three years adhered to the strict 3-step guideline. There was an odd patient here or there where I didn’t have complete staging available, and an even stranger situation where I lacked a biopsy diagnosis to confirm a previously harbored suspicion. Cases were simply managed the “ideal” way because we could demand that it be done.
When I left the hallowed halls of my academic training at veterinary school and ventured out in to the “real world,” I held fast to my upbringing as an oncologist. I only wanted to see patients who were confirmed to have cancer, as my goal was to focus my energy on their treatment rather than the pesky tests attached to their disease.
I’m not sure when the shift started, but I know it was fairly soon after I began working on my own that I realized I may need to bend my previously inflexible rules about patient care.
In order for me to build a thriving veterinary oncology practice and to accommodate the needs of my referring veterinarian population and owners, I would need to be okay with seeing pets without a diagnosis, to become adept at picking and choosing tests based on an owner’s ability to pay, and in some cases, treat pets without knowing exactly what was going on in their bodies.
In the real world, primary care veterinarians exist on a continuum, from small town one-doctor practices lacking what most of us would consider “basic” tools, such as in-house laboratory equipment and x-ray machines, to large-scale 24 hour emergency facilities who perform all of their own medical and surgical procedures.
There are plenty of cases where a primary care veterinarian suspects a pet has cancer, but either is missing the appropriate diagnostic device necessary to confirm things, or is unsure of the appropriate test to order and wishes to spend their client’s money wisely. Those pets definitely deserve the benefit of referral to a facility where they can have those procedures performed. And that is where I can help.
My knowledge and narrow focus of experience is extremely valuable in helping to guide owners and make recommendations for the tests I think would be most appropriate. I can go over the pros and cons of each approach and select the best plan of action alongside an owner, which is extremely empowering for them. This openness of discussion can sometimes come with the price of feeling frustrated with those cases where a definitive diagnosis isn’t achieved.
This happens most frequently because an owner literally “puts the brakes” on the testing algorithm I’ve previously outlined. Owners are typically comfortable with the non-invasive assays, such as lab work, radiographs or ultrasound exams. Once I start speaking of “biopsies” or “aspirates,” or even “surgery,” my suggestions are met with resistance, as the perception is that they are then putting their pet through “too much.”
Other times, owners have followed each of my recommendations, but the samples I’ve obtained are diagnostically inadequate. Infrequently, I’ll receive a cytology or biopsy report offering up an interpretation of “malignant neoplasia” or “poorly differentiated tumor.”
All this tells me is that the pet has cancer. It doesn’t provide any additional information as to the exact tissue of origin, the type of cancer, the risk of spread, or how to treat it. Those conversations are often the most difficult to have with owners, and more than a few times I’ve shared in their frustration when they tell me they’ve “spent X amount of dollars at your hospital and you haven’t told me anything new.”
When I haven’t actually “named” the disease but am asked significant questions regarding prognosis or treatment options, or even what to expect as the disease progresses, it puts me in an incredibly challenging position. I am obligated to tell owners the next most appropriate step to get us the answer we are looking for. But this can be met with significant resistance.
More frequently, I am expected to use my experience and instinct to make generalizations about outcome, even though that’s an impossible task to undertake. It is then that I find communication to be the key towards making sure everyone is on the same page regarding expectations, limitations, and potential outcomes.
There are times when I’ve moved directly to step 3 of my residency mantra without adequately and appropriately completing steps 1 and 2. I don’t enjoy knowing I’m doing nothing other than an elaborate and educated form of guessing when I prescribe a plan without a diagnosis. I also really hate envisioning my mentor’s thoughts about my actions.
Ultimately, as long as I know I’m doing the right thing for my patient, I’m content with mixing up the order of things from time to time.
I’ll admit, it’s a pretty great feeling when a sick patient gets better based on my intuition alone.