Dr. Susan Wynn, a veterinarian and veterinary nutritionist who promotes “holistic” veterinary medicine, has put up a couple of blog posts recently which I rather liked, so I thought I’d comment briefly on them. I more commonly find myself disagreeing with Dr. Wynn on questions of veterinary CAM, but she does often present a more rational and scientific approach to the subject than most proponents of “integrative” medicine, and I appreciate the few opportunities that arise to find common ground with those who have a different perspective or approach.
The more recent of the two posts consists of advice on how to critically evaluate veterinary medical information on the internet. I have also written about this subject, and I agree wholeheartedly with Dr. Wynn’s comments. The recommendations generally focus on being wary of excessively optimistic or unrealistic claims, sites with a commercial or rigid ideological bias, sites which rely on testimonials in place of properly published and relevant scientific research, and sites which refuse to disclose relevant information, such as the ingredients in the remedies they sell or the qualifications of the people offering advice. All of this is sound advice when looking for medical information on the Internet.
Dr. Wynn also published a post on the subject of evaluating the credentials of those offering veterinary medical advice, How to Avoid Phony Practitioners. For the most part, I agree with her advice on this subject as well, with an important exception I’ll get to in a moment. It is easy to make up impressive-sounding titles and initials, and not much harder to obtain a meaningless advanced degree through fake diploma mills, and this is common practice among those pushing alternative medical therapies. Not too long ago, I wrote about Primal Defense, a probiotic product marketed by Jordan Rubin, a charlatan who routinely tried to give his advice additional gravitas by acquiring fake degrees from unaccredited correspondence schools. If one is going to seek advice on veterinary medicine, it makes sense to give more weight to the advice of someone with years of training in veterinary medicine. Doctors are just as prone to cognitive errors as anyone else, of course, but we have the advantage of getting much of our information from the most reliable source available, scientific research.
My only disagreement with Dr. Wynn’s advice is that it ignores the importance of evaluating not only the quality and rigor of the training a practitioner receives, but also the plausibility and evidence for the subject matter in which they are trained. A credential from a rigorous and well-supervised program teaching astrology or witchcraft is not worth any more than a diploma mill credential since the approach is itself nonsense, and an expert in nonsense isn’t an expert in any meaningful sense of the word.
Dr. Wynn talks particularly about the various levels of credentialing in Naturopathy, but she completely neglects the fact that the discipline itself is a pseudoscientific, faith-based approach to medicine. In principle, naturopathy is a vitalist philosophy that looks to unseen energy forces to explain health and disease. In practice, it is a hodgepodge of sensible nutritional and exercise advice and loads of CAM, varying from the plausible-but-unproven to the completely bogus. The only common theme to methods used by naturopaths seems to be the notion of vital energies of one kind or another, as found in methods such as acupuncture, chiropractic, and homeopathy, which all rely in theory on mystical energies that no one can prove exist. And while naturopaths are theoretically trained to refer patients with serious medical conditions to conventional doctors, many are suspicious of conventional drug and surgical therapies. It is not uncommon for naturopaths to oppose vaccination and to promote not only supposedly “natural” approaches such as herbal medicine but also bizarre, dangerous, and manifestly “unnatural” therapies such as chelation therapy, detoxifying enemas, and so on. If the theory is nonsense and the specific practices unscientific, it doesn’t matter how rigorous the training is.
The same logic applies to Traditional Chinese Medicine, with it’s vitalist theory, idiosyncratic and unscientific diagnostic methods, and inconsistent and mostly unproven therapeutic practices. Chiropractic, likewise, contains a few bits of useful treatment for musculoskeletal pain and a load of nonsense and outright dangerous practices, and of course homeopathy is utterly worthless.
All the training in the world in a philosophy or method which has no value does not protect the patient from harmful or useless treatments. So while I generally agree with Dr. Wynn in terms of checking into the credentials of anyone offering veterinary medical advice, I would go farther and suggest that pet owners should look into the arguments and, most importantly, the scientific evidence concerning the philosophy and methods a particular practitioner offers as well.
did she ever get boarded in nutrition? I always think of herbs when i read her name.
I’m not sure. Her web site states she is still in her residency in clinical nutrition, so she may not be boarded at this point.
It does seem that she has become more evidence-based in the last few years, although she recently accused Narda Robinson of being racist for writing a critical review of TCM in veterinary practice news.
It does seem interesting that rather than embracing all forms of CAM fairly uncritically, some of the veterinarians who promote one or two forms of alternative medicine (acupuncture for Dr. Robinson, TCM and Ayurvedic ideas about herbal/”holistic” medicine for Dr. Wynn) are quite willing to apply scientific criticisms to other forms of CAM which they don’t favor. While this seems promising in some ways, it also tends to give the forms of CAM that they do favor more credibility than they deserve. I think you did a good job addressing these points in your post, but I think it bears repeating-the same level of scientific skepticism should be applied equally to all treatment modalities without exception. This is where Drs. Wynn and Robinson both fail, in my opinion, even though I do appreciate it when they write posts such as the two you are discussing here.
This is such an important issue: it’s difficult for the non-medically &/or scientifically trained to get a good grip on what’s being said in so much internet “information”. Thanks for opening the subject up.
Bartimaeus,
I don’t doubt we all tend to have blind spots for ideas we personally believe to be true, and we are less vigorous in our criticism and evaluation of them. The best I think we can hope for is a general recognition that EBM is superior to opinion and at least the attept to apply it where we can. We’ll never eliminate faith-based medicine, of course, but if we can separate truly useful new therapies from those that only look useful under uncontrolled observation, at east we can try to marginalize the nonsense as much as possible. In that effort, there is still some value to encouraging as much scientific rigor and self-critique as possible among proponents of CAM therapies as well as in the mainstream.
Somewhat related to this topic is a recent acupuncture stdy in the journal Pain. Though not blinded or placebo controlled, and thus not so useful for evaluating efficacy, it was primarily intended to see if the apparent benefit of acupuncture was associated with the level of training or experience of the doctor administering it. No such relationship wa found. This is consistent with the idea I discussed in the post that there is no value to extensive training in a modality that is not beneficial.
Interestingly, the only physician variable that did correlate with perceived benefit was subspecialty, with Internists getting more benefit than orthopedic specialists. My own theory is that since the treatment is a placebo, the benefit is associated with the doctor’s ability to create a positive relationship with the patient, and I bet surgeons and orthopods in general are not as good at this as the sort of folks who choose to practice internal medicine!
J Pain. 2010; 11(5):431-5.
Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture?
Witt CM, Lüdtke R, Wegscheider K, Willich SN.
The aim of this paper was to quantify the influence of the physician’s training and experience in the field of acupuncture on the outcome in patients with chronic pain. Patients visiting their physician because of chronic low back pain, headache, pain due to osteoarthritis of the knee or hip, or neck pain, were included in 4 multicenter, randomized, controlled studies. All patients received routine care; patients in the acupuncture groups received additional acupuncture treatment (on average 10 sessions). The data was pooled, and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined. A total of 9,990 patients (mean age 49.6 +/- 13.6 years, 68% female) treated by 2,781 physicians (mean age 46.3 +/- 7 years, 37% female) were analyzed. The physicians had 7.3 +/- 5.2 (mean +/- sd) years of experience in acupuncture and their mean duration of formal acupuncture training had been 287 +/- 321 hours. The outcome was
markedly improved in the acupuncture group. We identified only 1 physician characteristic with a significant influence on the outcome: Internists performed better (odds ratio OR = 1.49, confidence interval CI: 1.01;2.18; P = .043); orthopedists worse (OR = .79, CI: .62;1; P = .043) than the average physician. Neither the duration of training nor the duration of experience had any impact on the extent of the acupuncture effect. PERSPECTIVE: In this analysis, physician characteristics such as training did not influence patients’ outcome after acupuncture, suggesting that formal training parameters have only a limited influence on treatment effect. Other skills such as the therapeutic relationship, which are difficult to measure, may probably play a more important role and should be taken into consideration.
I agree, it is good that some of the publicly prominent veterinarians involved with CAM are not uncritical of all CAM, like some of the proponents of CAM on the human side seem to be. It just bothers me to see things like acupuncture promoted as a scientific, evidence-based practice when it really isn’t, as the paper you commented on illustrates. Becoming an “expert” in homeopathy seems to follow similar lines-there are huge lists of symptoms (including hundreds of variations on fever) that are supposed to be used to determine exactly which remedy to use, but in the end, it is still nonsense. The long lists and latin terminology just serve to impress the patient and create a “better” placebo effect, but I suspect a similar study of homeopathy would show no better outcomes for experts in homeopathy than anyone with an ability to connect with the patient and make them feel good about the encounter.
good article in the nyt this morning about the harm from herbs. Someone needs to do one about non fda compounded veterinary drugs sold in the states.
http://www.nytimes.com/2010/05/26/health/policy/26herbal.html?ref=health
I found this interesting quote from Dr Wynn from a alternative medicine newsgroup thread on the internet “straddling a wavy line”. I have no idea what most of those letters after her name mean and no idea what kind of “Georgia Veterinary Specialists” she is. What do you think?
Susan Wynn writes
I do frequent phone/email consults – to formulate diets based on the diagnosis of primary veterinarian, or for well pets. I may do that without the veterinarian being involved, but I always request medical records. As far as I know, many if not most of the veterinary nutrition services do this. Correct me if I’m wrong.
I OFTEN have clients ask for recommendations about herbs and nutraceuticals – I tell them that it isn’t appropriate to do this without a physical exam, but I’m happy to consult with their vet.
I’m straddling a wavy line, I think, but I agree that that if a veterinarian consults with a client, makes a diagnosis without a physical exam, and sends out treatments for that diagnosis – it’s practicing without a VPCR. Is it different for a formulated diet based on medical records? What do you think?
Susan G. Wynn, DVM,CVA,CVCH,RH(AHG)
Georgia Veterinary Specialists, Sandy Springs, GA
I believe the first two sets of letters following DVM are certifications in acupuncture and herbal medicine, neither of which I consider especially legitimate. I’m not sure what the last one is.
Dr. Wynn and I disagree about a lot of things, but I also find we are in agreement surprisingly often. I think what she’s saying here is correct, that formulating an individualized diet or “prescribing” herbs and supplements is something that ought to require a VPCR since these things have the potential to have significant effects on the health of the patient, and the appropriateness of these kinds of intervnetions depends on the condition, concurrent meds, and other individual factors about the patient that you need to know about. I do think it is common practice for nutritionists to formulate diets based on phone consultation with the owner or referring veterinarian, probably becuase there are so few nutritionists and they may not be close enough to the client to reasonably expect an in-person consult. There probably is no way to avoid this for logistical reasons, but it does create the potential for mistakes, especially if the consult is just with the client who may not think to mention relevant bits of history.
VIN.com has a thread called RACE discriminates against CAVM that is over one hundred post. Dr wynn and a frequent poster on this blog who is a DO teaching CAVM at a vet school take on this argument again and link to this blog entry. I would suggest any vet that can read the vin thread who is interested in so called alternative medicine and required by law CE read it. Vin is a online group of vets who help make unproven medical care the standard of care. The VIN group is attacking the DO who teaches at the Colorado vet school for here involvement in RACE denial of VINs herb course. The DO makes the point that the VIN CE herb course needs to be science based to be approved.
art malernee dvm
fla lic 1820
“The DO makes the point that the VIN CE herb course needs to be science based to be approved.”
…because the AAVSB/RACE standards stipulate that CE courses need to be scientific and based on evidence in order to earn approval from RACE.
Narda, I support your efforts on the VIN CE herb course thread. The thread is approaching 200 post and I am impressed how you with some support from others here have taken a stand on VIN. I have not seen such courage on VIN since bob imrie was alive. Did Alex almost get kicked off?
Robert Imrie on 03/30/2004 0:51:32 am ET
Of course, Susan Wynn’s co-author and frequent collaborator, alt med “guru” Allen Schoen, DVM, and other alt vet med proponents who managed to get themselves appointed to the committee charged with formulating the 1996 AVMA alt vet med “guidelines,” succeeded in coming up with a document that not only egregiously promoted unproven and disproved “CAVM” therapies, but failed to mention the nasty “science” word EVEN ONCE!
Perhaps in the future, if the AVMA elects to seat a “politically correct” committee to re-write the “Veterinarian’s Oath,” they can eliminate the “nasty science word” from the oath altogether. While I’m certain this would comfort the ever-growing proportion on “unproven therapy advocates” in the profession, I hope I’m long dead before it comes to pass.
Robert Imrie, DVM
art malernee dvm
Thank you, Art. That is very kind and means a lot to me.
No, I guess Alex wasn’t in jeopardy of being asked to leave VIN. I got confused after trying to catch up on emails and correspondence via the iPhone and not seeing the full message.