The Five 'A's of Evidence-Based Medicine, Rewired for Exam-Room Remarks

An offhand "Fluffy had a hairball ... but that's normal" at the end of a feline wellness visit can hide a genuine medical problem, and Dr. Kyla Savick, DVM, argues the same five-step framework used for evidence-based veterinary medicine (EBVM) — ask, acquire, appraise, apply, assess — is the right tool for interrogating it.

Writing in Veterinary Practice News, Savick, a small animal relief veterinarian and member of the Evidence-Based Veterinary Medicine Association (EBVMA), lays out how the classic 5 'A's cycle, normally reserved for resolving questions about treatments and diagnostics, can be redirected at the quiet remarks clients make on their way out the door.

Ask: turn a remark into a PICO question

The cycle begins with a clear, answerable question. In literature searches, the PICO mnemonic — patient/population, intervention, comparator, outcome — keeps search terms relevant, refined with synonyms, Boolean operators, and filters.

Client comments deserve the same rigor. When a client mentions "the usual hairball," the veterinarian first verifies the presenting complaint itself: distinguishing vomitus from regurgitated contents, expectorate, diarrhea, or urine. Savick recounts one client who insisted her cat had hairballs while describing liquid contents with no hair — "a hairless hairball."

Standard questions follow: duration, frequency, progression, contents. Then context-driven ones — did a diet change coincide with onset of vomiting? Are all pieces of the chewed plant or toy accounted for? The history matters materially: pertinent historical information improves diagnostic accuracy, while incomplete histories contribute to medical errors, a link documented in both veterinary and human medicine.

Acquire: go beyond the last weight on the chart

"Mittens lost weight, but he's just getting older" is the second trigger case. Acquiring information means knowing where to look — first at the practice's own records.

Savick recommends checking with team members that the weight was rechecked accurately today, then reviewing weight-history graphs, medication lists, and diagnoses in the electronic record to separate true downward trends from fluctuations caused by seasonal changes, medications, or illness. Exam notes on body condition score (BCS) and muscle condition score (MCS) help differentiate primary sarcopenia — generalized muscle loss from aging — from localized atrophy due to inactivity or nerve injury, and cachexia from disease or malnutrition. Reference labs and other clinics may also need to be called. Just as paywalls limit access to literature, incomplete records and unavailable staff limit access to the clinical picture.

Appraise: watch for the telephone effect

Appraising gathered information means testing its trustworthiness. A relative or caretaker rather than the primary observer may be transporting the cat; a team member may be paraphrasing the history — both scenarios risk missing or altered details, "like in the classic game of telephone."

Vague qualitative words demand scrutiny: "Snowball has slowed down recently" could indicate weakness from muscle loss, lameness, lethargy, or exercise intolerance, and "recently" can mean days to one client and years to another. Timelines and plausibility should be tested against alternative explanations — placebo effect, artifact, coincidence, or unclear — and clinicians should watch for erroneous or biased conclusions by clients, team members, and themselves.

Apply: age is not the whole answer

When a client says "Whiskers is too old for anesthesia/vax/preventatives," application means exploring what the client actually believes — that age intrinsically raises risk, that treatment is not worth the cost, or that a previous pet died after a similar procedure. Savick lists the factors that belong in the decision:

• Risks, benefits, and alternatives for each option
• Pain, anxiety, and risk management for each option
• Patient factors beyond age: comorbidities, cooperation, resilience, quality versus quantity of life
• Client factors: finances, capabilities, personal values and priorities

The goal is a spectrum of care — also called contextualized care — in which clients decide with full information.

Assess: close the loop, then restart it

Finally, outcomes need verification, formally through audit or informally through reflection. When a "blind and deaf" cat is instead diagnosed with cognitive dysfunction and started on dietary and environmental modifications, follow-up determines whether the plan worked. Savick points to the VISHDAAL sign checklist (vocalization, interaction changes, sleep-wake cycle disturbances, house-soiling, disorientation, activity changes, anxiety, learning/memory deficits) as an interim self-made tool, at least until the validated SeniCat questionnaire — under development with Morris Animal Foundation funding awarded March 28, 2024 — becomes available. A follow-up phone call or text also works. Client responses may send the case back to the start of the cycle.

Free resources supporting the approach include the EBVMA's QUIT Tool, ten yes/no questions that flag concerns in treatment studies, plus RCVS Knowledge's free EBVM Toolkit and CE courses; the 2021 AAHA/AAFP Feline Life Stage Guidelines and 2021 AAFP Feline Senior Care Guidelines cover distinguishing normal aging from disease in senior cats.

Savick closes with her own cat, Safire — diagnosed with a splenic mast cell tumor at 18, alongside chronic renal disease, anemia, arthritis, and other comorbidities, and treated successfully with splenectomy — as a reminder that age alone should never decide the case.