The Evidence-Based Veterinary Medicine EBVM Conundrum
“Dr. X said that one of his main purposes when discussing EBM/EBVM at meetings is to get students/practitioners to question their decisions (i.e., to be less certain about decisions they make). This invariably results in “push back” from some attendees, because they go to meetings in hopes of coming away with answers/information; not more doubt and indecision. In human medicine, they do not have that problem. Once a physician’s misled belief in old stereotypic (non-evidentiary) information can be torn down, they can readily be remolded along EBM lines because there is plenty of valid EBM results published. On the other hand, there is a paucity of hard-core EBVM studies in the literature, and without significant funding this trend will continue in the foreseeable future. However, that should not diminish the effort… to get students and practitioners to understand that what they learn and later practice as practitioners is based on this paucity, to factor that into their decision processes, and to demand more valid studies based on the principles of EBM.
Another point made was that students, in particular, have the misguided belief that consensus is evidence. This belief needs to be dispelled.”
The above statement was made in the context of developing projects and goals for an organization striving to promote evidence-based medicine within the veterinary field. It struck me as identifying a key problem for those of us in the field trying to change the culture of veterinary medicine to be more focused on scientific, evidence-based medicine EBM) and less on the “art” of medicine, by which we usually mean the following of hunches and intuition by doctors.
Of course, the first step towards recognizing the values of EBM is acknowledging the limitations of our own abilities to assess our patients’ clinical problems and responses to our interventions. This is challenging enough as it directly threatens our sense of knowledge and competence. Doctors often caricature EBM as a painting-by-numbers approach to medicine, where the doctor is a mere robot following the pre-programmed algorithms produced by some faceless research bureaucracy. This image speaks to the depths of the fear clinicians have about acknowledging the unreliability of their own judgment in the face of the vast body of information that constitutes modern medical knowledge and the dazzlingly complex organisms that are our patients.
I believe this fear is unfounded, as the need for and value of intelligent, talented, and hard-working people is not diminished by EBM. It is simply a tool that replaces our best guess with real information. But the fear is understandable and powerful, and must be addressed if EBM is to make any headway among veterinarians.
But the EBVM Conundrum speaks to a problem that lies in wait for us after we have faced the already daunting task of instilling a greater sense of skepticism about our own wisdom and abilities in vets. What body of reliable science and evidence-based information are we to use as a replacement for our intuition and experience? There can, of course, never be enough good clinical data, and some level of uncertainty will always remain to be bridged by individual judgment. But in veterinary medicine, we are particularly blighted by the lack of well-designed and well-conducted clinical research. This is primarily an economic problem, though the culture of veterinary medicine plays a role.
Funding such research often requires the deep pockets of industry or government. And while industry does support a lot of veterinary research, the profits to be made are miniscule compared to those in the human medical field. And industry money doesn’t come without an agenda which can influence the direction and results of research. Even with rigorous controls and the best of intentions, it has been clearly demonstrated that the source of funding has a consistent and significant impact on the outcome of clinical studies.
And the political climate has long been unhealthy for government sponsorship of independent research even in human medicine. Veterinary medicine cannot expect much public sector support of such research except in those areas that are, or can be made to seem, directly relevant to human health concerns.
The news is not all bad, of course. Some good quality veterinary clinical and basic research is done and published, funded by academia, private foundations, industry, and the others. And, with a wealth of necessary caveats, research already done concerning human health issues can provide some useful guidelines. At the least, such data can help us be wise in how we use the limited resources we have. If decades of extensive research in human medicine have revealed nothing of value in prima facie unlikely therapies such as homeopathy, therapeutic touch, acupuncture, and the like, we would be smart to take the lesson and not spend too much effort and money demonstrating the comparable lack of utility for such methods in veterinary patients.
There are many individual veterinarians, and some institutions with veterinary medicine, that see the medical and economic benefits and the practical and philosophical, and ethical value of making veterinary medicine a truly evidence-based, scientific enterprise. And these agents are contributing to the realization of this goal despite the obstacles I’ve discussed. As the opening statement points out, changing the culture among veterinarians to be more accepting of our own limitations and of the need for the tool of EBM is necessary part of the process of developing the solid, evidence-based guidelines clinicians need. And identifying such problems as the EBVM Conundrum improves our ability to plan how best to move the veterinary medical field in this direction.