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Annie [above left on the day she arrived] was a retirement present from my practice partners [2003]. Her first friend, Studly, [above middle] lives down the road, but eats and sleeps here [going home for the odd holiday]. Woofie, above right, showed up after a year or so as a stray, taking up full time residence after being shot in the chest [mistaken for a Coyote we think]. Annie has an electric fence encircling about an acre of our property because she is just not highway·<\/font>savvy, while the other two are free range denizens of the hood. Annie waits patiently at the edge of her domain while the boys go on their morning and evening walk-abouts.<\/p>\n <\/sup><\/font><\/div>\n <\/font><\/sup><\/div>\nThirteen years have passed, and things are a little different now. Annie has bilateral hip arthritis, and [untreated] lays around moping. But she can return to her old frisky self with a single dose of a<\/font>spirin a day. It’s remarkably effective, but getting her to take it is another matter entirely. She often turns her nose up at the liver flavored Nutri·Vet<\/em> doggie aspirin, even when sealed inside of a Greenie<\/em> [a pill pocket designed for such purposes]. So over time, we’ve learned that:<\/div>\n\n
if: we don’t feed the dogs automatically in the morning<\/div>\n<\/li>\nand if: we wait until Annie starts lobbying to be fed [by head butting my leg]<\/div>\n<\/li>\nand if: she hasn’t seen me preparing the aspirin bomb [broken up pill sealed in the Greenie]<\/div>\n<\/li>\nand if: we give her the bomb slightly reluctantly as a treat in response to her demands <\/div>\n<\/li>\nthen: she sucks it down with relish<\/div>\n<\/li>\nand then: we feed the dogs<\/div>\n<\/li>\n<\/ol>\nAny break in the chain, and we’re in a forced drugging<\/font><\/em> situation [not conducive to good inter·<\/font>species relations]. forced drugging<\/font><\/em> <\/font>is okay for a one shot heartworm pill or maybe a short course of medication like antibiotics for a discrete illness, but not for everyday meds. So every morning, the background issue around here is "Has Annie been bombed?<\/em>"<\/div>\n
\nLittle question that this is a story about how old people spend their time and about my lifelong attachment to dogs, but I have another agenda in the telling. In medical school and during the first part of an Internal Medicine residency, I think I had an algorithmic view of medications. This medicine is for these things. And that medicine is for those things. This is the dose for this med, etc. But then then came the clinical part of my Fellowship with our Rheumatology Group. Since many of those diseases are of unknown etiology, and the treatments are often empirical, things were very different: <\/div>\n\n
em·pir·i·cal<\/font><\/strong> \/ëm-pir-i-kãl\/<\/div>\n\n
adjective<\/em>: empirical<\/strong><\/div>\nbased on, concerned with, or verifiable by observation or experience rather than theory or pure logic…<\/font><\/div>\n<\/ol>\n<\/ul>\nAt first I thought I’d fallen in with a bunch of lunatics. On rounds, we’d spend forever retaking the history and repeating the exam. Then we’d retire to the ward conference room and have a long discussion about treatment, and about what parameters we’d follow to judge the effect of the treatment, whatever it was [and sometimes it was nothing, as in benign neglect]. I was used to the speed-dial ER mindset, and this seemed like a lesson in what it was like to have OCD in a war zone. E<\/em><\/font>very<\/font><\/em> treatment was a therapeutic trial<\/font><\/em> [emphasis on every<\/font><\/em>]. With every<\/font><\/em> medication trial, we were seeking a therapeutic window<\/font><\/em> in terms of dose. But after a time, I came around to see the wisdom in that way of thinking. We were using medications on the toxic end of the spectrum with crippling chronic diseases and the only solid proof was in the unique response in any given patient. It was a good lesson for all of medical practice. I never got over that way of thinking [and never plan to]. When I got to psychiatry, it was a natural fit [unknown etiology, significant toxicities, chronic course, proof in individual results, benign neglect option, etc].<\/div>\n
\n <\/p>\nBack to Annie. This aspirin choice came after trials with several other anti·inflammatories [GI problems] and some concoction being pushed by our vet called Zoom<\/em> [poor results]. With the aspirin, ½ an adult aspirin worked [~160 mg]; a baby aspirin didn’t [~80 mg]; so on to the 120 mg doggie aspirin which also worked – at least for now.<\/div>\n![](\"http:\/\/1boringoldman.com\/images\/annie-asa.gif\")
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\nWhile this little tale of Annie’s treatment has an obvious moral-to-the-story<\/font><\/em>, its moral only really works in a Marcus Welby, M.D.<\/a> world [Marcus Welby was a long-running television program about a doctor who devoted 24\/7 attention to the patient of the week, with no other apparent cases or duties] – a world in which every case is an Annie<\/font><\/em>. In case it’s not clear, my topics here are modern medical practice<\/font><\/em> and treatment guidelines<\/font><\/em> – obviously too big for a single post [maybe too big for a single blog]. But here’s a viewpoint piece from the JAMA that frames some of the issues:<\/div>\n\n