There was a thoughtful and cogent essay on the Kevinmd Blog today about a key element in doctor/patient (or in the veterinary case doctor/client) relationships: what happens to the relationship when you say “No” to people. This is certainly a common challenge for veterinarians, and it set me to thinking about situations in which we are required, in my opinion, by ethics to tell our clients things they don’t want to hear, and things that will not endear us to them.
In America there are be two well-known rules:
1. Nothing is ever nobody’s fault.
2. There is never nothing to be done.
(I apologize for the grammar, but I feel the emphasis is more appropriate than the better-written versions of these statements)
As an advocate for science-based medicine, because I truly believe it leads to better health and well-being for patients than opinion and faith-based medicine, I have an ethical responsibility to own up to the limitations of scientific knowledge. I cannot claim one unifying cause for all disease (toxins, subluxations, unbalanced ch’i, dietary deficiencies, and on and on). And I cannot claim to always know why a particular clinical problem affects a particular pet. Philosophically and personally, I am comfortable with some degree of scientific indeterminism, and I believe it is possible that some things simply can never be predicted or fully understood. But even in the more pragmatic, practical world of applied medical science, the reality is that there is much we don’t know, and pretending that we have all the answers is misleading and wrong.
Unfortunately, people don’t like uncertainty, especially when it involved illness, and they tend to view the claim that something bad happened for reasons we don’t understand, or even possible just by chance and so for no good reason at all, as unacceptable and likely a cover for incompetence. Not being able to identify a clear and simple cause for something means we cannot control or prevent it, and this makes us afraid, and fear makes us angry. Facing this anger and dealing with it compassionately, and yet honestly, is a tough part of our job as veterinarians.
It is very difficult to tell a client that we do not know why their pet has a particular medical problem, and even more difficult to then deny them the comfort of the unproven, or even outright bogus theories they come up with or that others offer them. But part of our ethical responsibility to our clients, and the way we earn the trust they must ultimately have for us to do our jobs, is that we must be honest, even when dishonesty might provide some comfort or make us look better.
Along with admitting to the limitations of our knowledge, I believe we must be honest about the knowledge we do have. When we know that 98% of cats under 10 years of age who present with bloody urine do not have urinary tract infections, we must deny the client the antibiotics they may want from us even if we could make the client happy and get the credit for the pet’s subsequent improvement. We know they won’t help, and may even hurt the patient, and we have a responsibility to admit and make appropriate use of that knowledge. Giving antibiotics for infections that are likely viral and vitamins and other supplements that have no demonstrated value are common practice among physicians, and likely veterinarians as well. They serve our need to do something, and the clients’ need to get something for the trouble and expense of coming to see us. However, they are illusions, not medicine, and ultimately I don’t believe they benefit our patients, clients, or profession.
The same holds true for any implausible or outright unproven medical approach. While our clients are likely to perceive improvement, at least in the short term, with almost anything we do (thanks to a placebo effect by proxy), giving a placebo is a form of lying and is essentially unethical and contrary to the principles of a legitimate veterinarian/client relationship. This is especially true for vets as the placebo is more likely to benefit our clients than our patients, who are better served by real therapies.
CAM therapies can have an advantage over science-based medicine in that they frequently offer direct and simple (though false) explanations and treatment protocols. CAM providers seem rarely at a loss for an explanation or a treatment, and though I am sure it must sometimes happen, it seems very rare that a CAM provider will admit that they don’t know why something bad has happened and that they do not have anything but comfort and support to offer. Part of the mythology that CAM treats causes rather than symptoms, and part of the reality that CAM often makes clients more satisfied with their care than mainstream medicine, has to do with the sense of confidence and certainty (however unjustified) that allows CAM providers to avoid admitting helplessness or uncertainty when we who are dedicated to dealing in evidence and truth cannot avoid it.
There are many other examples of situations in which we are obliged by ethics to say no to clients or tell them something they don’t want to hear. Denying requests for tests, medications, or procedures that are not appropriate for the patient, recommending tests and procedures which are appropriate even if we fear the client may object to the costs, honestly (though gently) explaining their own responsibility for some medical problems and the actions they need to take (overfeeding and obesity, poor medication compliance, etc), and admitting our mistakes are all painful but necessary elements to a veterinarian/client relationship.
It is understandable that we may be tempted to shirk such painful communication, and it is certainly easier in the short run to do so. I have even met veterinarians who based long, financially successful careers on the routine practice of giving clients want they want regardless of what is medically appropriate or best for the pet, and of routinely lying to clients. However, I believe the ethics of our profession, the dictum to do no harm if we are not certain the need or benefit justifies it, and the principle of trust based on honesty in our relationships with clients often requires us to say “No” and to tell clients things they would rather not hear from us In the long run, I also believe we provide better care for our patients if we act this way, and that the short term advantages of false hope and even outright dishonesty cannot compete with the benefits of sticking with the truth, even if it may not always be what we wish it were.
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As I read this, I was reminded of parents with autistic children who shun “conventional” therapies regardless of their proven outcome, in favour of chasing all sorts of alternative and abusive treatments.
Lying practitioners of any sort are despicable. They prey on the desperation and ignorance of the credible population.
Would I have wanted to witness my cats with terminal illnesses suffer until they died at home for my own selfish purposes? No.
I think the world has gone mad. I was unaware until several years ago that this nonsense even existed in the veterinary world.
Keep fighting the good fight and thank you for your blog.
Jackrabbit,
Thanks for you comment and support. It seems I spend a lot of time saying things people don’t particularly want to hear, so I always appreciate it when what I say resonates with someone else’s understanding.
Scientific medical care must be cost effective not only to the client but the veterinarian must get paid to practice it. Refusing to practice what the FDA defines as Fraud does no good if the loss of income puts you out of business.
FDA definition of fraud quoted in Sept/Oct 93 NCAHF Bulletin Board: The deceptive promotion, advertisement, distribution or sale of articles, intended for human or animal use, that are represented as being effective to diagnose, prevent, cure, treat or mitigate disease (or other conditions), or provide a beneficial effect on health, but which have not been scientifically proven safe and effective for such purposes. Such practices may be deliberate, or done without adequate knowledge or understanding of the article. (Quoted from a letter from M L Frazier – Director, State Information Branch 6/18/93).
art malernee dvm
Well, I don’t think it’s often a choice between practicing questionable or bogus medicien and going out of business. While some clinets may leave if they can’t find a particular CAM therapy they want, CAM is still a relatively small (though sadly growing) part of the veterinary market. And good, scientific medicine is still ultimately good for business because it works better, and regardless of philosophy people will go where they get results.
I’ve had clients who came to me with a preconception that woo is what their pets needed, and when we talked about the evidence and their choice, they chose to stay and go with science-based medicine. When their pets got better, that had a big impact on their perceptions of CAM and conventional medicine.
Granted, everyone has to make a lviing, buy supplies, pay rent, pay employees, and both CAM and mainstream medical providers have to pay enough attention to the business end to make these things possible. But for most vets, it’s not so key a factor tat I think it dictates teir choices of therapeutic approaches.
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Well, I don’t think it’s often a choice between practicing questionable or bogus medicien and going out of business. >>>
Thats the only sentence of your last post I may not agree with . It depends on how do you measure the word “often”? I have found independent studys that show most of a vets take home income in the USA is from bogus or questionable medicine. That income must be replaced with real medicine income some how. Until the profession can figure out how do do that, those whistle blowers who lead the way may starve before the standard of care and the laws get changed. I do not see a lot of general human practitioners practicing evidence based medicine and making a good living either. I think it is more what the population is used to paying for a service that affects their willingness to pay. Of course, it is also affected by the affluence of the society we live in. So science based doctors can hope the smart people have all the money.
“I have found independent studys that show most of a vets take home income in the USA is from bogus or questionable medicine”
I’d like to see the studies you refer to, because I find this very hard to believe. But we’ve disagreed before, on vetsurgeon.org, about what “evidence-based” means, and I know you seemed to take the most extreme view, sometimes used by CAM proponents to mock science-based medicine, that without a solid RCT no practice is every justified. If that’s the approach here, then I still have to disagree. But perhaps you have something else in mind?
I know you seemed to take the most extreme view, sometimes used by CAM proponents>>>>>
Proven vs. Unproven Treatment
Unproven treatment relies on relative efficacy and safety that has not been shown in controlled peer-reviewed clinical trials.
If a proven treatment is not available (which is often the case in veterinary medicine), or if the treatment not work for the individual patient (also more common then we would like), i see nothing wrong with trying an unproven therapy, as long as the doctor tells the client that using unproven medical care is more likely to harm than help. I think that unproven care should be called investigational medical care when the drug company or the doctor is trying it. When the FDA measures multi million dollar drug studies submitted for approval even then after spending millions only about one out of five pass the mustard. Studys show that expert review cannot be trusted so you cannot rely on the standard of care either. Using unproven medical care is like playing the lottery. Some win but most loose. The odds are against you.
Again, I think your perspective is unrealistic and excessively pessimistic. Yes, a treatment made up out of nothing but magical thinking (Bach flower essence, homeopathy, chiropractic) is very unlikely to work. However, even most of these are not directly harmful, so I don’t see a sound basis for your belief that harm is more likely than not without thorough RCT testing.
Most of the therapies you would label “unproven” are not made up willy nilly but extrapolated from established knowledge of physiology, pharmacology and so on. If you read the section of Hill’s Criteria, you should realize that clinical trial evidence is only part of establishing the truth about an intervention. If one has established biologic plausibility, coherence with established knowledge, in vitro and animal model evidence, and pilot clinical trial evidence, then one is a lot closer to a justifiable claim of efficacy. Sure, one may still turn out to be wrong sometimes, but these elements to establishing safety and efficacy still have meaning.
And as you point out, there are situations in which action is necessary despite imperfect knowledge, We must of course be honest with our clients about the limitations of our knowledge and evidence, but I think claiming we have to identify all therapies as “investigational” that havn’t been supported by perfect clinical trial evidence is inappropriate and comes perilously close to fulfilling the cliche that Dr. Messonier and others market about evidence-based medicine being exclusibely about RCTs and thus essentially useless in the verterinary domain where we rarely have this level of evidence.
communication is difficult for me. My reply post got rejected so I posted it on sidewiki if anyone wants to read my rejected reply.
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