I recently came across an interesting paper that cited some of my previous writing about the relationship between evidence-based medicine and alternative medicine.
M.A. Memon, J. Shmalberg, H.S. Adair III, S. Allweiler, J.N. et al. Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges. Open Veterinary Journal, (2016), Vol. 6(1): 44-56.
This article presents an argument for how and why alternative therapies should be taught in veterinary schools under the heading of Integrative Medicine. This argument contains a number of reasonable points and also a number of significant flaws. I’ll begin with the points of agreement between my view and that of the authors.
Where I Agree
The paper starts by arguing that because many CAM therapies are sought by animal owners and have a certain degree of popularity, veterinarians are likely to encounter them. While the authors cite some specific numbers about the popularity for alternative therapies that are a bit misleading, there is no doubt that most vets will regularly encounter questions about alternative therapies from clients. Since one of the most important roles for a veterinarian is as an educator helping clients make fully-informed decisions about the care of their animals, it is necessary for vets to be knowledgeable about those CAM therapies clients may seek or already be using.
Of course, the most appropriate response to clients questions about such methods is often to explain the lack of plausibility and supporting evidence behind the practice and discourage its use. And if vet students are to be taught about CAM, the controversial issue, of course, is precisely what they should be taught about these practices. That will be addressed shortly, but in any case, vets do need to understand the claims made about CAM therapies and the evidence available regarding them, and having some formal introduction to this subject in veterinary school makes sense.
Another point on which the authors and I agree is that such instruction about CAM practices should not be provided or funded by organizations with a primary mission of promoting or teaching CAM. I have discussed previously the role of the AHVMA and AHVMF, the Chi Institute, and other CAM training and advocacy groups in promoting alternative therapies, often blatantly disregarding or misusing scientific evidence to further their agenda. Any involvement of such groups in teaching CAM would introduce a severe risk of bias and likely make such training more a marketing exercise rather than a legitimate, evidence-based means of preparing vets to answer client questions about CAM.
While I agree with the authors about the importance of minimizing the risk of bias in the teaching of CAM in veterinary schools, I am not convinced that this can be readily achieved. This article, for example, was itself a product of an effort initiated and conducted in association with the American Academy of Veterinary Acupuncture, so it already involves exactly the kind of support from a group advocating for a particular CAM therapy which the authors are acknowledging can introduce bias into the teaching of CAM. In addition, a number of the lead authors are also instructors at the Chi Institute, members of the AHVMA, and otherwise affiliated with CAM advocacy groups that have a clear bias with regard to the safety and efficacy of alternative therapies.
And as I have discussed before, the very question of expertise in CAM raises the issue of potential bias. Almost no one pursues advanced training or certification in an alternative medicine practice unless they are irrevocably committed to a belief in its value to patients. However, in the case of some such therapies, there is substantial reason to doubt whether the principles or practices for which such expertise is defined have any reality at all. Being an expert in homeopathy, for example, is a bit like being a Catholic priest. The expert undoubtedly has extensive knowledge about the relevant subject matter. But by itself, this knowledge doesn’t demonstrate the objective reality or truth of this subject matter to those outside of the belief system, and such expertise is of little value to those who are not already believers.
If only CAM “experts” are involved in teaching CAM to veterinary students, the content of this education is going to necessarily be rooted in beliefs about the underlying truth of the matter regarding these therapies which are not widely accepted by scientists and conventional healthcare providers. Even if an effort is made to include some skeptical input into these courses, it will be difficult to find outsiders who have put the time and effort into investigated the claims of CAM advocates and understand their theoretical and evidentiary limitations.
The inclusion of such skeptics, when they can be found, doesn’t entirely solve the bias problem in any case. This potentially sets up the presentation of CAM as merely a difference of opinion among scientists or clinicians. This may be true for some CAM practices, but for others (homeopathy being, again, the classic example) there really is no substantive difference of opinion among scientists, simply a consensus based on evidence which a small group of true believers refuse to acknowledge.
So while the ideal of a course which teaches vets what they need to know to effectively answer client questions and provide guidance about CAM in an objective, evidence-based way is laudable, in practice it seems very difficult to achieve. In fact, the very premise of his article, that there is benefit to patients in a strategy which integrates the disparate domains of conventional and alternative medicine, is debatable, as I will discuss shortly.
Finally, there are a number of other points on which I agree with the authors of this article. They are clear that any discussions of CAM with students should emphasize relevant research evidence appraised critically rather than simply personal or anecdotal experience, historical traditions, etc. The limitations of such evidence should be explicitly presented, the critical issue of placebo effects should be addressed, potential risks as well as potential benefits should be communicated, and CAM therapies should not be presented as replacements for established conventional treatments. I also agree with the authors that many conventional medical practices lack strong supporting research evidence, and it can be appropriate to consider alternative therapies that have the same level of basic plausibility and limited supporting evidence as such conventional treatments when the urgency of intervening justifies the uncertainty about the effects of doing so.
Where I Disagree
There are also, however, many points on which I would disagree with the authors of this article. Perhaps the most obvious is the merits of the very concept of Integrative Medicine. If we can demonstrate a particular therapy is safe and effective using appropriate scientific testing, why does it require a separate category, whether we label it “alternative or “integrative,” to be utilized as part of our overall treatment approach? If we test a therapy, show it works, and begin using, how is it not simply another tool of conventional or science-based medicine?
Tim Minchin has most eloquently delineated the real meaning of terms such as complementary and alternative:
By definition…complementary and alternative medicine…have either not been proved to work or been proved not to work. Do you know what they call alternative medicine that’s been proved to work? Medicine.
Or, perhaps less poetic but still to the point, as Dr. Marcia Angell has put it:
There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted.
The concept of integrative medicine requires that we combine therapies that are in some sense viewed separate but equal. But what is the nature of this difference? The usual differences that turn out to justify this separateness include: a theoretical foundation that is incompatible with established scientific knowledge; a lack of supporting scientific evidence; or a committed group of supporters who believe a therapy is safe and effective based on anecdotal experience or historical and cultural tradition despite the absence of supporting scientific evidence.
There is no reason to integrate a plausible and scientifically proven therapy into mainstream medicine but preserve for it a separate identity as “alternative.” If we treat all proposed therapies equally, evaluating their mechanisms and clinical effects at every level through rigorous research, then we can simply accept those that prove their value and abandon the rest. The only use for a special category of Integrative Medicine is to present some therapies as equal in legitimacy to conventional treatments before they have been properly tested and proven their worth.
Another problem with the concept of Integrative Medicine is that it is arbitrary in which practices it encompasses. Since most of the authors of this paper practice acupuncture, of course that is included in their suggested course material. Botanical or herbal medicine is also included, and one could claim this is justified since this is one of the most popular CAM practices. However, dietary supplements are arguably even more widely used, and they aren’t mentioned in this category or under “integrative nutrition.” Are these an alternative therapy to be integrated, based on scientific evidence, with conventional treatments? They are usually marketed as such by CAM practitioners. Or, if such supplements are shown to be safe and effective for particular conditions, are they simply yet another element of scientific medicine? My use of fish oils for atopic dermatitis and arthritis isn’t practicing “integrative medicine.” It is just making use of a nutritional intervention with reasonable plausibility and supporting research evidence in the usual course of scientific medicine.
Similarly, the authors identify Physical Rehabilitation as a key content category for an integrative medicine course. While there is a disappointing lack of research in this area involving veterinary patients, physical therapy is an established, ordinary part of conventional human medicine. There is no reason to create a special category to teach this in an evidence-based way to veterinary students. It should be included in the curriculum just like any other mainstream medical practice.
On the other hand, the authors suggest that the philosophical and theoretical principles of TCM and homeopathy should be taught as part of integrative medicine despite being completely inconsistent with the principles and established knowledge of basic science. The authors take something of a “teach the controversy” approach similar to that used by creationists.
The argument is that we should teach the different points of view and let students make up their own minds. Of course, this is nonsense when the context is the explicit education of students in science and science-based medicine. There is no controversy about biological evolution in science, so no need to teach religious or philosophical alternatives in the science classroom, though these may be worth studying in the domains of religion, history, cultural studies, and psychology. Likewise, there is no scientific controversy about potentization by dilution and succession or the role of Excess Wind in generating disease. These are religious and philosophical ideas which have no place in the science classroom.
If the authors believe it worthwhile to expose veterinary students to pseudoscientific or anti-science views of health and disease for the purpose of preparing them to refute these when asked about them by clients, there might be some merit to that idea. However, this needs to be done with the explicit and clear intent of inoculating students against such ideas. And the course material should then include energy medicine, Bach flower essences, Reiki, intercessory prayer, and other widely available faith-based health practices. However, the authors do not suggest that a major focus of the course should be preparing veterinarians to refute or discourage alternative medicine practices. The exclusion of some unscientific philosophical views and inclusion of others in the suggested curriculum seems to be mostly a feature of the authors’ own views of what is clinically useful. Once again, bias proves slippery and difficult to eliminate from a course on CAM approaches.
The reluctance to explicitly refute any CAM practice, regardless of the evidence, is a consistent problem in alternative veterinary medicine, though conventional vets sometimes seem just as unwilling to reject implausible or disproven CAM practices and CAM vets. Unfortunately, science works primarily not by validating but by rejecting hypotheses. The key to its effectiveness is that our biases tend to lead us to confirm our existing beliefs, and the tools of science that limit the misleading effects of these biases tend to help us reject our hypotheses when they are mistaken. While scientific research is often seen as primarily useful for confirming what we already think we know, this is actually not how it works best.
There is almost no hint in this article of the important role of any course addressing CAM in discouraging therapies that are clearly incompatible with science or have been shown pretty reliably not to be effective. How can we teach vets to respond effectively to client questions about healthcare practices if we are unwilling to ever acknowledge that some are ineffective or harmful and should be discouraged?
These authors represent a group of veterinarians with legitimate expertise in scientific medicine, and they have produced a thoughtful and interesting document. While I agree with a number of their key points, I think it is a bit misleading to call this a “consensus guideline.” It is only the consensus among individuals with a pre-existing belief in the premises of their own argument. All the authors believe acupuncture is a useful therapy, though that is not something one can reasonable call established by good science. Many believe more generally in the value of Traditional Chinese Medicine as a method for evaluating disease and choosing therapies, despite the deep incompatibility of this faith-based folk system of metaphors and the principles, methods, and knowledge base of science. And all the authors believe in the concept of Integrative Medicine as a useful schema for evaluating alternative therapies and integrating them into mainstream clinical practice. All of these beliefs are controversial and outside the mainstream scientific view.
Ultimately, the type of curriculum proposed here would almost certainly function as a Trojan horse for alternative therapies. CAM practices would be treated as different but equal to conventional practices, and this would create the impression that they can be reasonable accepted and employed regardless of the plausibility of their underlying mechanism or the evidence for their clinical effects. Though the authors claim to agree with my assertions elsewhere that all potential interventions should be assessed by the same, soundly scientific standards, they have advocated the concept of integrative medicine, which ultimately fails to accomplished that. Rigorous testing of individual interventions and acceptance or rejection on their merits does not require that some practices be viewed as special and be “integrated” with conventional medicine. These practices should, if they prove their worth, simply be “medicine,” and they should be taught as such.
I do still agree with the authors that some attention to CAM should be paid in the veterinary school curriculum in order to prepare students to answer questions and guide clients in the use or rejection of these practices. The best way to accomplish that, however, isn’t clear. I personally think an explicit course in Integrative Medicine will inevitably have an inherent bias towards promoting CAM practices as equivalent to conventional interventions regardless of the quality of evidence or the compatibility of the basic theory with established science. It might be better to have a section in a broader course about Evidence-Based Medicine which is devoted to Evaluating Unconventional Therapies. Such a section could illustrate the application of EBM methods to the panoply of CAM practices, from the plausible and well-studied to the disproven or inherently unscientific and faith-based. Students would learn about these approaches in a way that emphasized the need for a consistent, science-based approach to evaluating all potential interventions, rather than the perspective of seeking out CAM therapies to be integrated into clinical practice based on anecdote first and then scientifically evaluated later all while maintaining a distinct ideological identity as “integrative.”
This approach would best serve the needs of both vets and animal owners. Vets would get a better, more thorough instruction in how to use science most effectively to make decisions and recommendations about all possible interventions, and all ideas would be treated equally and fairly and judged by the same epistemological standards. The fundamentally ideological categories of CAM and Integrative Medicine would be unnecessary. Those practices that prove their value through the usual route of scientific investigation would simply be “medicine,” and those that did not would simply be unproven or failed hypotheses, not entitled to special treatment simply because of the faith some vets or owners have in them or their historical origins.