The Five ‘A’s cycle of evidence-based veterinary medicine (EBVM) is used to investigate clinical questions about treatment and diagnostic choices, but can also be used to investigate clients’ inconspicuous remarks about potentially significant health concerns. After patiently addressing every exam finding and question for an elderly cat’s routine wellness visit with “no concerns,” you turn the doorknob to leave, but pause with a moral dilemma. “Yeah, Fluffy had a hairball ... but that’s normal.” Wait, what? No vomiting was reported, and the comment was said so inconspicuously. You could rush to your next appointment, perhaps even sneak a bite of your forgotten lunch on the way, but then you remember the promise you made: to be the voice for those who cannot speak. You pull the exam door closed. During routine wellness or even sick visits, clients make offhand comments that could be the tip of the iceberg regarding real health concerns, but their nonchalant disposition suggests either a lack of concern or a lack of understanding of the significance of their comments. These quiet, latent remarks not only need to be addressed, but should be addressed with as much commitment as any other concern discovered during the history or exam portion of the visit. It requires critical thinking and strategic investigative skills, much like those used in evidence-based veterinary medicine (EBVM) to guide clinical decision-making.1 In fact, it can be helpful to use an approach that mirrors EBVM’s cycle of five ‘A’s: ask, acquire, appraise, apply, and assess.2 While these steps are intended to guide decision-making by resolving questions about treatment and diagnostic choices, they also help address health concerns (unknowingly) presented by our clients. Let’s use a few familiar remarks about elderly cats to see how these steps can help us uncover the bulk of the concern hidden beneath the surface. Ask “It’s just Fluffy’s usual hairball.” Asking entails creating a clear, answerable question to help find relevant information. This seems straightforward when we want information about treatments or diagnostics, but a mnemonic like PICO (patient/population, intervention, comparator, outcome) reminds us to include relevant terms in our literature search.3,4 We may need to fine-tune the search, by using synonyms, Boolean operators (“AND”, “OR”, and “NOT”), or filters. Similarly, off-hand client comments should trigger a series of clear, answerable questions, starting with open-ended questions and then fine-tuning. This guides us to the relevant information needed to confirm whether the comment is a true health concern and to narrow our differential diagnoses. First, we verify the accuracy of the presenting complaint itself, in this case, differentiating vomitus from regurgitated contents, expectorate, diarrhea, or urine. Clients may not appreciate subtle differences in expulsion behaviors (if witnessed) or expelled contents. I even had one client insist her cat was having hairballs rather than vomiting, but she described the contents as liquid with no hair. It was a hairless hairball. Next, we ask for standard information: duration, frequency, progression over time, contents of the vomitus, etc. Then we fine-tune our history questions based on the case’s context. Does the change in diet coincide with the onset of vomiting? Are all pieces of the damaged plant or toy accounted for? While “standing around” asking history questions may feel less productive than actively examining or performing diagnostics, its importance should not be overlooked. Pertinent historical information can improve diagnostic accuracy, while an inaccurate or incomplete history can lead to medical errors, underscoring the importance of asking.5,6,7 Acquire “Mittens lost weight, but he’s just getting older.” The next step in the cycle is to understand which sources of information are available and accessible. When searching the literature to answer clinical questions, we can use resources, such as databases and other online platforms.3 Similarly, when we want information to corroborate a client’s comment, we need to know where to look. Obviously, for weight-loss concerns, we can simply look at the most recent weight, but it can be more nuanced than that. First, we consult with team members to verify whether the cat’s weight was rechecked today to ensure accuracy and whether appropriate scales and techniques are consistently used at each visit. Next, we review our medical records to confirm trends. In electronic records, viewing a weight history graph or a list of medications and diagnoses helps us distinguish true downward trends from fluctuations due to seasonal changes, medications, or illnesses. Viewing exam notes, we can further assess body condition scores (BCS), muscle condition scores (MCS), and any other relevant exam findings to help us differentiate primary sarcopenia (generalized muscle loss from aging) from atrophy (localized muscle loss from inactivity or nerve injury) and cachexia (generalized fat and muscle loss from disease or malnutrition). Finally, we may need to call other clinics for previous medical records or reference labs for clarification on flagged test results. Just as access to literature can be limited by memberships and fees, access to information about our case may be limited by incomplete or substandard medical and communication notes, or by the unavailability of team members and after-hours clinics.7,8 In summary, going beyond isolated facts in the medical record is essential to acquire relevant insights into the complete clinical picture. Appraise “Snowball has slowed down recently.” Now that we have acquired the information we need, we must appraise its value. For literature, this involves assessing research quality, potential bias, and applicability (clinical significance and relevance to our scenario) to determine whether the information is sufficiently trustworthy to incorporate into our decision-making (See: “Additional resources”).9 Similarly, for our client’s comments, we should assess the information we have gathered for trustworthiness. Additional resources The Evidence-Based Veterinary Medicine Association created the free QUIT Tool to help veterinary professionals flag concerns (using 10 yes/no questions) in treatment studies. The RCVS Knowledge website provides a free EBVM Toolkit and free continuing education EBVM Courses for busy practitioners about using the 5 ‘A’s to help incorporate EBVM into daily practice. The 2021 AAHA/AAFP Feline Life Stage Guidelines and 2021 AAFP Feline Senior Care Guidelines provide information ranging from preventative to advanced care in senior cats and differentiating normal aging from true health concerns. Sometimes, a relative or caretaker rather than the primary observer brings the cat to the clinic, or one of our team members is paraphrasing the history, both situations potentially leading to missing or altered details, like in the classic game of telephone.8,10 Other times, information must be clarified because it is subjective, vague, or contradictory. “Slowing down” could indicate weakness due to muscle loss, lameness, lethargy, or exercise intolerance. Qualitative words like “recently” (“sometimes,” “small amount,” etc.) are highly open to individual interpretation, ranging from a few days or weeks for some clients, months to years for others, or “ever since” a particular medication, procedure, or diet change. Consequently, we must be cognizant for erroneous or biased conclusions by our clients, team members ... and ourselves.11 Timelines and plausibility should be scrutinized to determine whether a conclusion is potentially real, a placebo effect, an artifact/outlier, coincidental, or unclear. These are just a few ways we can appraise information provided by our clients. Apply “But Whiskers is too old for anesthesia/vax/preventatives.” We are finally ready to apply the information. The appraised value and applicability of the literature are considered before choosing whether and how to incorporate it into our personal decision-making process or our clinic’s practice guidelines (See: “Additional resources”). Along the same lines, when clients remark about a cat being “too old” for a procedure or treatment, we should consider the context of both the comment and the case. Does the client believe age intrinsically makes vaccines or preventatives more dangerous? Or do they feel diagnostics and treatments are not worth the costs and effort because they presume the cat’s lifespan is at its end? Did they or a friend have another pet that passed away after a similar procedure? It’s easy to want to support clients when they say, “I don’t want to put her through that, considering her age,” but it is just as important to consider: Both risks and benefits of the procedure or treatment plan, and alternative options Ways to address the patient’s pain, anxiety, and risks for each option Patient factors (other than age)–comorbidities, cooperation and resilience, quality vs quantity of life, etc. Client factors–finances, quality of life (time, physical, mental, and emotional capabilities), personal values and priorities, etc. Having asked, acquired, and appraised the information provided by our clients, we are better equipped to apply a spectrum of care (a.k.a. contextualized care), helping them make educated decisions based on all aspects of the case.12,13 Assess “Socks is going blind/deaf with age.” Applying the information is not the last step. We need to assess the outcome of the changes implemented to verify whether improvements were made. After incorporating evidence from the literature into our decision-making or practice guidelines, we can assess the impact formally (e.g., audit) or informally (e.g., individual or group reflection).14 To assess the impact of changes regarding our client’s comments, we can similarly use formal or informal methods. After gathering and appraising information about a client’s comment that her cat is going blind and deaf (and ruling out other medical causes), it is determined that Socks is actually experiencing cognitive dysfunction rather than blindness and deafness, and that dietary and environmental modifications are a good starting point. However, without following-up, we cannot know if the cat benefited. We could use a formal method like a self-made questionnaire about feline cognitive dysfunction signs VISHDAAL (vocalization, interaction changes, sleep-wake cycle disturbances, house-soiling, disorientation, activity changes, anxiety, learning/memory deficits), at least until a validated questionnaire like SeniCat becomes available.15 Or we could use an informal method, such as a simple follow-up phone call or text message, to assess progress. Based on the client’s responses, we may need to ask more questions and restart the entire cycle of 5 ‘A’s. The author’s cat, Safire, was diagnosed with a splenic mast cell tumor at 18 years old. At the time, Safire had chronic renal disease, chronic non-regenerative anemia, arthritis, cognitive dysfunction, possible restrictive cardiomyopathy, and even a history of radioiodine. After much consideration of the options, the patient’s comorbidities and personality, and the client’s personal values, a splenectomy was pursued to improve the quality of life (by removing a potential source of discomfort) for her remaining days, knowing this could be very limited. This photo shows Safire celebrating her 20th birthday earlier this year. Although this success story is anecdotal, the point is to remember age is not the only factor to consider in our decisions. Photo courtesy Kyla Savick, DVM Final thoughts While ask, acquire, appraise, apply, and assess are meant to provide an EBVM framework for answering clinical questions, they also hold true for investigating unrealized health concerns that clients casually mention. It is about discovering what is really going on beneath the surface, whether the client truly does not realize that their comment could indicate a real medical issue, has been misinformed by the internet or their peers, or perhaps had a bad anecdotal experience in a similar situation. It requires patience, empathy, precise non-judgmental language, active listening, and clinical reasoning when communicating and sorting through the information. When we are already tired and overwhelmed, these inconspicuous remarks are easily overlooked, but they are just as important to address. With focus often placed on treatment and diagnostics, hopefully, this article serves as a reminder of the value of teasing out our clients’ subtle, understated concerns and confirming the facts. Kyla Savick, DVM, has had a passion for animals, science, and logic since childhood. Graduating from Western University of Health Sciences in 2012, she has been a dedicated small animal relief veterinarian for over a decade. She joined the Evidence-Based Veterinary Medicine Association (EBVMA) to learn more about the discipline and is humbled to share her newfound knowledge with readers of Veterinary Practice News. References Cockcroft, Peter D., and Mark A. Holmes. (2003) Handbook of evidence-based veterinary medicine. Blackwell Publishing Ltd. https://doi.org/10.1002/9780470690833 RCVS Knowledge. “Evidence-Based Veterinary Medicine (EBVM): An Introduction.” https://www.rcvsknowledge.org/approach/evidence-based-veterinary-medicine/evidence-based-veterinary-medicine-ebvm-an-introduction White, Constance, Heather K. Moberly, Erik D. Fausak, Clare Boulton, Julia Shrubb, Laura McGillycuddy, Sally M. Everitt, Sandra D. 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