Clinical concepts of relevance to a ECPHM exam

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Clinical concepts of relevance to a ECPHM exam

• General Assembly
• Brussels
• June, 12, 2005

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Clinical concepts of relevance to a ECPHM exam
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Clinical concepts of relevance to a ECPHM exam
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Clinical concepts Limited rationality Country
effect Cultural specificities Medical
specificities Fuzzy logic
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Concept of limited rationality
Our preferences Our traditions Our knowledge
acts
These acts are not necessarily the best choices
but they are those giving the greatest
satisfaction
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Concept of limited rationality

• We have to do something even before to really
  think with uncertain, imprecise and imperfect
  data even if

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Limited rationality in a Practitioners brain
for many reasons his/her own knowledge
and experience (K), knowledge of the client
(K), knowledge of the herd (K), etc
OK
How1 ? Action
OK
(KKK)
No effect
How2 ? Action
No effect
(KKK)
Herbert SIMON, Nobel Prize, 1978
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Concept of limited rationality
The hidden traps in decision making (eight
psychological traps) Anchorage trap Status quo
trap Sunk-cost trap Confirming-evidence
trap Framing trap Overconfidence trap Prudence
trap Recallability trap
Hammond et al., 1999 Clin Lab Manage Rev
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Only in Texas
Only in Australia
Our preferences Our traditions Our knowledge
with a very marked country effect all countries
have their own culture
Only in France
Only in USA
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 Country effect  and  Medicine  our
preferences, our traditions, our knowledge

• Not so easy to illustrate
• example phobias
• agoraphobia
• acrophobia
• apopathodiaphulatophobia
• leucosélophobie
• sidérodromophobie
• microbiophobia

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Prescription of antibiotics in Humans in EU
(1997-2002) (Defined Daily
Doses / 1000 habitants)
Goosens et al. The Lancet. 2005 365 579-587
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 Country effect  and  Medicine  our
preferences, our traditions, our knowledge
Low titers Circulation of Leptospire in the herd
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I sent these results to three  major  swine
vets Australia, USA, Canada with the same
history and the same description of the symptoms
I have received three answers Australia Probably
negatif USA May be positif Canada I dont
know
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Schools of though

• Clostridium perfringens A (England)
• Clostridium difficile (France)
• Mycotoxins (Germany)
• Urinary Tract Infection (France)
• Leptospirosis (France)

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Even if schools of thoughs, we may have a common
general approach
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Why a such clinical approach?

• The clinic is a science that encompasses
  characteristics-a very high sensibility to
  initial conditions
• -  vagueness  (imprecisions, uncertainty,
  imperfections)
• It is therefore necessary to use a method
  designed to manage this  vagueness  in a
  rational way (concept of limited rationality)
  within a  complex system 
• Paretos law ( 20-80  law)

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Paretos diagram reasons of surgery program
perturbation A Delay of medical staff B Delay
between 2 interventions C Incomplete file D
Modification of the Patient s willingness E
Emergency F Lack of sterile material G Non
respect of schedule H Other
dysfunction origin
Cumulative of dysfunctionment
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Non clinical field Clinical field Science
 Non-science  Rigorous  non
rigorous 
Certainty Preciseness Perfection ?5
Uncertainty Vague Imperfection  Fuzzy logic 
Common denominateur Science

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Statistics are to information what a lighting
post is to a drunk a source of support but not
of enlightenment
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imprecisions, imperfections, uncertainties
In clinics, -There are always missing pieces
to the puzzle (imperfections) -Some pieces dont
fit too well (imprecisions) -Some pieces appears
to fit in many different places (uncertainties)
So what ?
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 Linguistics variables 
Criteria of feasibility Very
Few Impossible Criteria of truth Very Few Fa
lse Criteria of  probability  Very Few Unlike
ly
Uncertainty data Imprecise data Imperfect data
Fuzzy logic
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Methodological approach in population medicine
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Before the visit
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Why this deficit of the previsit phase ?

• Veterinarians
• Producers
• Diagnosis laboratory
• Technicians

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Why this deficit of the previsit phase ?

• Veterinarians
• Training
• Individual medicine
• Perception of population medicine
• Lack of recognized generalized approach
• Producer
• External culprit
•  We have only to submit to the lab  

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Why this deficit of the previsit phase ?

• Diagnosis laboratory
• Accepted ideas (Pasteurians)
• Confidence it is written
• Always answers
• Technicians
• Training
• External culprit
• Training (engineer-like)

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Clinical investigation

• Therefore, clinical science is NOT different from
  the other veterinary sciences
• But a major country effect
• training (undergraduate)
•  School of thoughs 
• sanitary situation

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Clinical concepts of relevance to a ECPHM exam
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1-2
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Some comparison North America / Europe

• Uniformisation
• DVM
• Swine cont ing
• education
• Production

Europe EAAAV IPVS, nothing else Currency (E)
Harmonisation nothing else
North America AVMA / NAVLE IPVS, AASV,
Leman, ISU, GYC Currency () Costs (HCR)
Early weaning Feed Feeding ...
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Some comparison North America / Europe
PRRS Disease n1 Reproduction Gilts
Foxcroft theories Management Dry
feeding Pathology PRRS PMWS
PRRS Disease n1 in some countries (Italy)
Area PRRS positive (F Britanny), but IA
Center negative (F) and positive
(Italy) Reproduction Gilts French vs Danish
system Management Wet and dry feeding
Pathology Mycotoxins (G) and bacteria
(F) PMWS (SP), UTI (F)
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According to the European country
Classical Hog Cholera
Infection / Disease Wild pigs
Germany versus France
Aujeszky disease
Infection / Disease
Spain versus France
A. pleuropneumoniae serotype 12
Pathogenicity
Denmark versus UK
B. hyodysenteriae
Country effect (lab availability)
Hungary versus Belgium versus France
General diagnosis methodology
Necropsy versus Broncho-Alveolar Lavage
Germany versus Other EU countries
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12 units (2 to 5 days)
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• Epidemiology and methodology 3 days
• Economy, management and policy 3 days
• Meat technology and quality control 2 days
• Environment, Welfare and Behavior drugs,
  clinical trials 2 days
• Nutrition, nutritional diseases
• enteric diseases 3 days
• Feed processes, formulation, feedtechnology
  2 days
• Genetic 2 days
• Reproduction and diseases of
  reproduction 3 days
• Housing, management of the production
  records 3 days
• Respiratory diseases 3 days
• Regulated diseases, programs of prevention 2 days
• Use of laboratory of diagnosis necropsy 3
  days

31 days
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Poland ( hyopathologist )

• 42 days of training
• 12 week-end/year x 2 years

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E-learning
The German Interactive, internet-based training
program Pig Herd health Management  for
veterinary practitioners
J. Heitzhausen and Th. Blaha, IPVS 2004
17 courses 15 authors (all German ?) Control by
multiple-choice-test
Results ?
Content ? (all references are in German) How many
veterinarians involved in this program ?
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Objective

• We (ECPHM) have to clearly define our objectives
• Are practitioners well trained as well as well
  received and well  digest  a continuing
  education ?
• Scientific news
• in which language ?
• Which journals ?
• Which proceedings (which meeting) ?
• Are practitioners out of standing clinicians ?
• Who is able to judge ?

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European recognition
Large Pan-European recognition
Narrow Pan-European recognition
Ex Reproduction versus Viral diseases (PRRS,
Influenza)
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Example regarding solving problems

• Analysis of production
• Cost of production
• Ventilation (building)
• Feeding and Nutrition
• Slurry management
• Diseases management
• Herd strategies
• i.e. one site vs 3 sites
• change of Genetic
• ...

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Proposals

• Ad hoc ECPHM Committee (3-4 countries)
• country according to the number of swine vets
• country according to other criterias (pig
  production ? Existing programs ?)
• Survey
• Available information from each countries
• Swine practitioners  need from each country
• Be careful
• Faculties are not practitioners
• ECPHM have to be recognize by each countryand by
  practitioners

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Conclusions on
Clinical concepts of relevance to a ECPHM exam
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Why becoming Diplomate ?
Ability, knowledge, skills,
Capacity
recognition
Willingness
Opportunity
Tools, equipment, working condition, mentoring,
time, pay,
Motivation, job satisfaction,job stimulation,
self-image, personnality,
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Conclusion
Clinical practice is a science, not an art
Criteria of feasibility Very
Few Impossible Criteria of truth Very Few Fa
lse Criteria of  probability  Very Few Unlike
ly
Uncertainty data Imprecise data Imperfect data
Fuzzy logic
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Conclusion
imprecisions, imperfections, uncertainties
In clinics, -There are always missing pieces
to the puzzle (imperfections) -Some pieces dont
fit too well (imprecisions) -Some pieces appears
to fit in many different places (uncertainties)
So what ?
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