A date with my Hero

Hero LOVES getting inside a brown paper bag. (Always cut the straps so your cat never gets caught up as this will lead to a mega freak out).

It sounds frivolous and even a little awkward but SAT's "date with your dog" column is a not-so-thinly veiled attempt to remind readers of the simple joys of spending time with the non-human companions that wait so patiently while we go about our ever-busy lives.

I realise I may be preaching to the converted, but even I need a bit of a reminder sometimes to put down the laptop and give my undivided attention to the furry family.

And I did promise it wasn't all dogs. This week I wanted to highlight what I believe are the favourite activites I share with my cat Hero. I met him as a patient - at eight weeks old he required a forelimb amputation. We developed a bond and I adopted him from his rescuers - the Cat Protection Society of NSW.

Hero likes to lounge around on his Kong Naturals Incline Cat Scratcher  - and better still like's to borrow someone else's and make a bed out of it.

Hero is up for a lie down anytime of the day or night. He's exceptionally adept at sleeping in any position.

Glamping. Sounds a little convoluted, I know, but if you have an active cat pitch a tent in jump in. That's Hero launching himself at the wall and biting my arm. Definitely an activity he enjoyed more than I did.

Possessing only 75% of his limbs has hardly been a hindrance and Hero still expects full-on playtime. These are the activities I think HE enjoys most...

Number 1 by a mile: sitting on the kitchen bench (no matter how many times I gently pick him up and put him down on the floor) and pretending not to watch me prepare food.

Almost forgot: Stashing toys and bits of paper. My role in this is to throw toys and bits of paper down the hallway. Hero does the rest.

There are plenty of things you can do at home, without investing in expensive toys (or overpaid butlers) to entertain your cat. Check out this post on enrichment for the apartment-dwelling cat.

Learning and teaching veterinary science in the age of information overload

How do you learn veterinary science well, and how on earth do you teach well, when there is so much information to wrestle with?

As a lecturer I am frequently asked for study tips and strategies by veterinary students. However, earlier this year I was informed by one student that she had found the Holy Grail: a book entitled How to Study in Medical School by Armin Kamyab.

I critiqued this book (read the post here) on the grounds that I felt it placed far too much emphasis on memorising everything taught, leaving little room to acquire experience in what is an overwhelmingly hands-on field.

Kamyab's system is based on several problematic assumptions, one of which is that everything taught in the medical curriculum is worthy of equal consideration, equal revision and hopefully absorption. Discipline, he argues, is the answer.

But if we extend this to the veterinary curriculum, my own experience tells me that discipline is not enough. What happens when we reach capacity, or information overload?

In 1980 – well before the internet, social media and any form of portable telecommunication – Anderson & Graham raised concerns about the impact of information overload on medical education. They performed a loose analysis of the amount of information taught in the medical curriculum and determined that undergraduate medical students had to assimilate 27,000 facts and 25,500 concepts in their clinical or senior years (roughly 9 facts or concepts per hour).

The authors concluded that there was a need to establish the “best and most efficient means of transmitting and assimilating information” (Anderson & Graham, 1980). That was 23 years ago. Surveys of veterinary students at Murdoch University and the University of Queensland identified information overload as a major stressor (Williams et al., 2005; McLennan & Sutton, 2005). But it isn’t just undergraduates suffering under the weight of too much information (read the late Dr Lee Lipsenthal's arguments in this post).

Graduates, too, are struggling with the onslaught of new research, new technologies, new techniques and aggressive marketing of veterinary continuing education (every week there seems to be a new provider springing up somewhere).

An old tree near the Main Quad at the University of Sydney.

According to some, the rate of information overload is no longer relevant. Veterinary educators long ago recognised the inadequacies of the traditional assumptions underpinning undergraduate teaching (Bushby, 1994, see table 1).

Table 1. Rules defining traditional veterinary medical education

Assumptions underpinning curriculum...	Problems with that assumption...
There is a core of information that must be learned.	No two teachers agree on the core; The core is difficult to refine (one attempt resulted in a program consisting of 216,000 objectives or one fact every six minutes
Teachers will tell the student what they must know.	Assumes that teachers know what needs to be learned; Assumes students are passive, surface learners.
Teachers must cover the material.	If students don’t learn it is their fault; teachers are dissociated from the learning process.
The teacher determines the organisation of material and method of instruction.	The student plays no role in deciding how the material is organised or learned.
With sufficient knowledge students will learn to think	Students do not feel in control of learning and are only exposed to critical thinking late in the course.
The only valuable information is that which is stored in your head.	Memorisation, superficial understanding and guessing are rewarded; exploration, inquiry, thoroughness and reliability are penalised.

Adapted from Bushby (1994).

The argument against the traditional model is compelling, yet my own experience as a veterinary undergraduate – and feedback from my students – tells me that we have significant attachment to this model.

The most compelling evidence, to me, was interviewing students last semester as part of my Graduate Certificate in Educational Studies (if you're interested in this course visit here). 

When I interviewed veterinary students last semester about learning, 100 per cent stated that they had learned something when they had memorised it. Not when they could explain it, no mention even of applying that morsel of knowledge. On Saljo’s hierarchy of learning, these excellent students only reached the middle. And memorising something is far different from applying it. 

One of my lecturers once said that "vet school is wasted on vet students", i.e. they don't have a context to hang those factoids they are learning, nor an appreciation of their relative importance, so it doesn't make sense til they graduate by which time they've forgotten a large proportion of said factoids. I got what he meant - but does it have to be that way? If we move away from the assumptions that to be a good vet you need to memorise every fact taught in vet school, and good veterinary teachers teach good veterinary facts, what are we left with?

[Sorry for the cliffhanger, but this is a topic I will be posting on further. I am genuinely keen to hear from students, veterinary educators and vets about their take on the problem - is it really a problem? How do you learn? What is a good teacher and how can we teach veterinary science best? Send me an email or post a comment].

References:

Anderson J and Graham A (1980) A problem in medical education: is there an information overload? Medical Education 14:4-7.

Bushby P (1994) Tackling the knowledge explosion without overloading the student. Australian Veterinary Journal 71:372-374.

McLennan MW and Sutton RH (2005) Stress in veterinary science students: a study at the University of Queensland. Journal of Veterinary Medical Education 32(2):213-218.

Trigwell K (2001) Judging university teaching. International Journal for Academic Development 6:1, 65-73.

Viner B (2010) Success in Veterinary Practice: Maximising Clinical Outcomes and Personal Well-Being. Oxford: Wiley & Sons.

Williams SM, Arnold PK, Mills JN (2005) Coping with stress: a survey of Murdoch University Veterinary Students.

Linear foreign bodies can wreak havoc on pet health

Never leave cats unsupervised with string. They have a way of swallowing it and that can spell disaster.

Gastrointestinal foreign bodies - i.e. objects that animals eat that they really shouldn't - are commonly seen in small animal practice. Clinical signs vary from subtle malaise to intermittent vomiting to the severely affected, moribund patient. It all depends on exactly what the foreign body is, where it is and how long it has been there.

Gastrointestinal tract (GIT) foreign bodies (FBs) can cause complete obstruction of the gut - i.e. the intestine is totally blocked, usually resulting in severe pain and more obvious clinical signs; or partial obstruction (often associated with more subtle, more chronic signs).

Linear foreign bodies (LFBs) - string, tinsel, fishing line, rope - often lead to partial obstruction and can be challenging to diagnose. In a recent study, LFBs were associated with a lower survival rate (80% in dogs and 63% in cats) compared with discrete FBs (94% in dogs and 100% in cats) (Hayes 2009).

In other words, LFBs are a recipe for gastrointestinal chaos. Sometimes they pass without causing obvious clinical signs - but that isn't great either. Some pet owners will say "oh, my cat eats string all the time and gets away with it". This is dangerous as they will present much later for veterinary attention if the LFB DOES cause problems. (Its also the reason why a lot of veterinarians were up in arms about this ad for ladies products - some owners might conclude that these are fantastic cat toys when the combination of an expandable object and string makes them doubly dangerous).

There is a big risk that LFBs anchor somewhere in the GIT - most commonly the base of the tongue or the pylorus. As the GIT moves everything through via peristaltic waves the anchored linear foreign body becomes taut - the intestines become plicated (as seen in the photo below). 

Nope, the intestines are NOT meant to be bunched up like this and yes, they are red and angry with inflammation. This is a very sick dog. He made a full recovery thanks to emergency surgical intervention. Then went home and ate a remote control. [Lesson: dogs don't always associate eating dumb things with feeling sick. They WILL be repeat offenders].

The LFB becomes increasingly taut and then acts as a saw through the intestinal wall, usually at the less surgically accessible site (the mesenteric border). This leads to peritonitis. Because signs may be subtle or intermittent, animals may not present until later in the clinical course. In the study by Hayes, a longer duration of clinical signs, the presence of an LFB and multiple intestinal incisions (often required to remove LFBs) were associated with an increased risk of mortality.

But timely surgical intervention is life saving. My colleague May and I wrote up a case we treated together in the Centre for Veterinary Education's Control and Therapy series - and this one had a happy ending. To view (it does contain multiple surgical images so not for the non-surgically minded) please click here.

Reference:

Hayes G (2009) Gastrointestinal foreign bodies in dogs and cats: a retrospective study of 208 cases. Journal of Small Animal Practice 50:576-583.

Animal events in October and November

Don't miss the Working Dog Conference.

If you're in Sydney this month, the University is running a suite of excellent animal themed seminars, symposia and conferences that you can pop along to as a student or guest.

This Thursday at 1pm Professor Annie Ross will be discussing Indigenous Knowledge and the management of dingoes and dugongs (in the vet faculty's Webster lecture theature). 

The Indigenous seminar series, organised by Dr Jaime Gongora, will also include a talk in Thursday October 17 (same time, same venue) by Bill Gammage - "The biggest estate on Earth: How Aborigines made Australia". The following week, AMRRIC's Julia Hardaker will discuss "Building better futures for animal health and welfare outcomes."

HARN seminar on November 4.

On November 4 the Human Animal Research Network is running a seminar entitled "A plague on our house: obesity, pests and the devil's cancer" which I will be chairing.

From 12pm in the Woolley Common Room, speakers include Professor Katherine Belov ("Sympathy for the devil: how do we stop a contagious cancer?"; Professor David Raubenheimer ("Penny wise, pound foolish: geometry, obesity and the cost of food") and Professor Edward C. Holmes ("The greatest evolutionary experiment: viral biocontrol of rabbits").

If working dogs are more your thing the Australian Working Dog Alliance is hosting its inaugural working dog conference on November 4 and 5. It promises to bring together working dog breeders, trainers, handlers, vets, vet students, facility managers, dog researchers, advocacy and Government group representatives from Australasia.

The program looks really interesting and there is a strong contingent of Sydney Uni researchers who will be discussing, among other things: the measurement of optimism in dogs, the attributes farmers value in their dogs, the economic impact of farm dogs, the genetics of canine separation-related distress and defining "dogmanship" (or should that be "dogpersonship?") - ie the way some people have with dogs.

For more information visit www.workingdogalliance.com.au/conference 

Pattern recognition vs problem based approach to veterinary cases: we need both

Just like Mr B and Phil, pattern recognition and problem based analysis may seem poles apart on the diagnostic continuum, but a recent paper in JVME argues that we must use both.

“In an ideal world, every patient would display unambiguous signs of disease confirming to classical textbook descriptions, and the clinician’s pharmacy would be an assembly of rational and efficacious therapeutic agents that would collectively address all the diseases of the animal kingdom. Unfortunately, the ideal world is not the real world, and a series of limitations relating to all aspects of diagnosis and therapy make veterinary medicine (as with human medicine) a “science of uncertainty’” – Stephen May, 2013.

As a veterinary student I operated under the assumption that one qualified I would be a clinician working in the ideal world, as described by May. I believed that once I graduated and was in full command of all veterinary knowledge, I would be able to manage cases and determine the single correct diagnosis and treatment plan. It turns out that companion animals don’t read textbooks. They certainly don’t follow them.

The type of clinical reasoning taught in veterinary schools is one which assumes certainty – when that can lead one up the (wrong) garden path in practice.

It may be the wrong garden path, but if I unleashed my guinea pigs here there would be a lot more path and a lot less garden.

In a recent article in the Journal of Veterinary Medical Education, Royal Veterinary College Deputy Principal Stephen May highlights one of the major flaws of veterinary curricula: the mixed messages it sends about clinical reasoning. Students are taught problem-based learning and discouraged from relying on pattern recognition, when pattern recognition clearly has merit.

The article makes an important distinction between scientific reasoning (with its emphasis on objectivity, presupposition that the observer stands outside the process, solving scientifically framed questions with appropriate technology, and where data requirements are saturated) and clinical reasoning (more subjective, where the clinician is part of the process and outcome, problems are not neatly framed, datasets are incomplete and ultimately the clinician must act in the absence of complete knowledge or data). Unlikely scientific reasoning which begins with a hypothesis, clinical reasoning starts with a problem and works forward, on the basis of probability, using inductive logic, to determine the most likely answer.

May discusses two major forms of reasoning: type 1 being consistent with a pattern recognition approach (this is intuitive, rapid and a not always conscious response to cues); with type 2 being consistent with a problem based, analytical, first-principles approach. It is much more demanding time wise – we tend to use this kind of thinking when presented with an unusual condition, an uncommon presentation of a common condition, or when something tells us this just isn’t right. Type 2 reasoning requires a large working memory.

He argues persuasively that type 1 and type 2 reasoning are complimentary and should be used together. We may arrive at an answer via type 1 reasoning but should be prepared to cross check where any doubt is present.

“It is essential that experts and novices alike be aware of the need and have the capacity to resort to analytical reasoning when cases are difficult,” he writes.

But he adds that it is dangerous to assume that type 2 reasoning is free of bias or free from error. It requires some accurate framing of the problem, and because it employs rules it is prone to error in cases where those rules don’t apply.

So sound clinical reasoning involves weighing up probabilities, cross-checking our gut feeling with the available dataset and the rules we know we can apply, and being aware of gaps in our knowledge and limitations in our thinking.

Sir William Osler, cited by May, expresses this beautifully:

[Medicine is the] practice of an art which consists largely in balancing possibilities. It is a science of uncertainty and an art of probability…Absolutely diagnoses are unsafe and made at the expense of conscience.

To study the phenomenon of disease without books it to sail an unchartered sea, while to study books without patients is not to go to sea at all.

It is wonderful to see that clinical reasoning has become a subject of study unto itself. Thinking through problems is central to what veterinarians do. One of my colleagues, a retired equine practitioner, told me “vets are decision making machines. You could make 1000 decisions in a day.” The mechanisms of decision making therefore impact on clinical outcomes and patient wellbeing and are worthy of our attention in their own right.

Reference

May SA (2013) Clinical reasoning and case-based decision making: the fundamental challenge to veterinary educators. Journal of Veterinary Medical Education 40(3):200-209.

Coco's long weekend

Coco takes it easy.

Its a long weekend downunder, today's post is simply a reminder to repay a bit of that sleep debt we all acquire so easily. SAT will be back to normal service tomorrow. In the meantime here is demonstration of appropriate long weekend behaviour by Coco.

A variation on this pose is excellent when members of your household are watching weekend sport. 

Unless its the cricket. A girl has her limits.