Several times in the past, I have written about he potential usefulness of cranberry extract in various forms for treating or preventing urinary tract infections (UTI) in dogs and cats. The last time I covered the subject was way back in 2017, and the evidence was still not conclusive, in veterinary patients or humans:
There is weak theoretical justification for using cranberry products for UTIs, though none of the supporting preclinical evidence involves dogs or cats. There is conflicting clinical trial evidence in humans, and no clinical studies in dogs and cats.
This [Cochrane] review indicates pretty clearly that overall, cranberry juice is not effective in preventing UTIs despite theoretical reasons why it might be. This illustrates, yet again, why we cannot rely on extrapolation from pre-clinical or in vitro studies to tell us what will work in actual patients.
The in vitro portion of this study is consistent with existing research that suggests cranberry extracts may reduce the ability of some bacteria to stick to the lining of the urinary tract. This could theoretically help prevent some urinary tract infections, though clinical research in human patients suggests this doesn’t really work to a significant extent in living people.
The portion of the study looking at prevention of UTIs in actual dogs, unfortunately, doesn’t help establish what benefit, if any, this product might have.
Despite some promising laboratory studies suggesting cranberry supplements might help prevent or treat urinary tract infections, the evidence of studies in clinical patients has been disappointing. Conflicting studies in humans suggest, on balance, that there is probably no significant benefit. And now a high-quality clinical trial in dogs has failed to find any effect, even in the the of infections the pre-clinical research most strongly suggested there should be one.
While the risks of cranberry supplements are probably negligible, pet owners should understand, and veterinarians should make in clear to their clients, that there is no good reason to believe they have any real value in preventing or treating urinary tract infections.
Here we are nine years later. Surely, the question must have been answered definitively by now? Yeah, about that…
A recent systematic review evaluated the research evidence to date on the topic.
Limited data are available regarding the use of cranberry or cranberry extracts for the prevention or treatment of infectious urinary tract disease in dogs and cats…While indirect evidence from humans and in vitro data from dogs and cats suggests the potential for efficacy, the small number of studies, small sample sizes within those studies, and low certainty of evidence preclude confident assessment of the role of cranberry for the prevention or treatment of infectious urinary tract disease in dogs and cats.
Despite decades of claims, research, and clinical use in patients, we still can’t say with any confidence whether or not cranberry, in whatever dose and form, is at all useful.
This is a common situation in veterinary medicine, where resource limitations and cultural factors rarely allow for large-scale, robust scientific evidence to answer such questions with confidence. However, in this case, the greater resources and efforts made in humans haven’t proven a whole lot better.
Cranberry juice reduced the rate of UTIs about 27% compared with a placebo liquid and appeared to improve symptoms somewhat.
Cranberry juice also appeared to reduce the use of antibiotics by about half compared with a placebo liquid.
Other forms of cranberry supplement didn’t seem to be helpful.
The evidence for benefit was only moderately certain.
Another recent review found similar benefits, but not for certain groups, including elderly people in institutions and people with neurological conditions impairing their urination.
Bottom Line The inconclusive nature of the veterinary research, and the caveats and nuances of the human literature, make it effectively impossible to say whether any form of cranberry supplement will benefit individual dogs or cats at risk for UTI. There is no evidence for significant safety concerns, and if using these products reduces excessive or inappropriate antibiotic use in patients with urinary tract disease, that might be an indirect benefit. Still, it is frustrating that we still cannot have confidence in the effects of these products, and should remain skeptical of the claims made for them by manufacturers and others with opinions based on anecdotal evidence.
I was recently asked about a specific acupuncture technique which pops up from time to time– needling or injecting medications at the location known as GV20 for calming or sedating effects.
It is always problematic to evaluate specific claims in acupuncture because-
Almost no one understands this, and acupuncturists have invented many complex and scientific-sounding ad hoc explanations for how acupuncture is supposed to work. These explanations are typically unproven, and while they explain some of the effects of needling and electrostimulation (and any other minor local trauma), they don’t support the broad, system effects proponents claim for acupuncture
Almost no one understands this, and acupuncturists are always identifying special characteristics for particular locations they claim as treatment points. Unfortunately, you can find something “special” (nerves, blood vessels, tendons, etc.) at nearly every point on the body, but again there is no convincing, consistent evidence that the collection of locations used for acupuncture is real.
There are many clinical studies of acupuncture treatment. Some look like they show meaningful benefits. This is mostly an illusion made out of placebo effects, bias and error in study design and reporting, tooth-fairy science, and minor non-specific effects from sticking needles in things. The bottom line is that acupuncture is mostly placebo, non-specific local effects of minor trauma, and the effects of other interventions credited to acupuncture.
Almost no one understands this, and the sheer size of the acupuncture literature is enough to convince a lot of people despite the fatal flaws in it.
All of this makes any attempt to challenge claims about specific acupuncture treatments challenging, and probably pointless. A thorough critical evaluation of studies around the use of GV20 is arguably meaningless if GV20 doesn’t exist and no one who believes in acupuncture will change their mind no matter what the results are. Despite that, shouting science into the void is arguably a majority of the content of this blog, so here goes….
What is GV20? The short answer is that it is an imaginary construct that acupuncturists claim as a functional and anatomically specific treatment location.
Traditionally, the governing vessel has been said to “connect all yang vessels in the body and functions to regulate local qi and blood, and modulate the balance between yin and yang”1 as well as to regulate “liver fire” and “internal wind.” This, of course, is all meaningless nonsense, but despite claims to the contrary it is how this and other acupuncture treatments are determined. Attempts to find “scientific” explanations for specific points and how they work are all post hoc rationalizations for a system still founded in this kind of pseudo-religious folk mythology.
Consistent with the general trend in acupuncture to look in an area that pre-scientific folk medicine claims is special and then report whatever is found there to be the reason for why the location is special and therapeutically relevant, many papers have characterized the anatomic and physiologic features of location of “Governing Vessel 20” or “Baihui.” It has been identified by anatomic landmarks relative to the skull, ears, or hairline, the purported presence of cranial or peripheral nerves, the presence of connective tissue, proximity to the central or precentral sulcus of the frontal lobe, and other criteria.1–4 Somewhat circularly, it has also been identified in terms of the supposed clinical effects of doing acupuncture there.
The purported uses for acupuncture at GV20 include3,d brain and bone marrow disorders, palpitation, stroke, loss of consciousness, chronic or acute infantile convulsion, sunstroke, irregular menstruation due to deficiency and cold in the lower jiao, dysmenorrhea…brain
disorder and mental disorder, such as heaviness of head, dizziness., vertigo, manic-depressive disorder, epilepsy, palpitation and poor memory; headache, dizziness, eye pain and redness, irritability, hypertension, anal, uterine, and vaginal prolapse and hemorrhoids; nasal obstruction and allergic rhinitis and insomnia.
This broad list is typical of claims for acupuncture, and other folk medicine traditions, which are often a hodgepodge of unrelated symptoms and conditions reflecting the foundations of these methods in vague theory and the accumulation of trial-and-error anecdotes. Most commonly, GV20 is used with the intention of sedating or calming pets for veterinary treatment, including potentially to reduce the dosage needed for sedative and anesthetic drugs.
While this sounds like a worthy goal, given that such drugs do have risks and unwanted effects, it is critical to establish that this treatment actually works and doesn’t have its own unwanted effects before using it as a substitute for well-established and thoroughly studies science-based treatments. We do not benefit our patients by believing we have made them more comfortable and withholding necessary drugs if that belief is false.
GV20 and the Evidence Acupuncture research inevitably raises the issue of Tooth Fairy Science. It is possible to generate extensive and impressive data and statistics evaluating imaginary treatments, and these data mislead rather than enlighten us. If Qi and Yin/Yang and meridians and points don’t exist, if they are just folk medicine metaphors unconnected with physiological reality, then clinical trials studying them can never give us reliable evidence about the value of treating them.
Acupuncture, of course, is an especially challenging practice to tests scientifically. While the folk-medicine theories behind it are nonsense, sticking needles in tissue actually does something, and it is fair to ask whether this something might have some value anyway. However, studies of acupuncture are nearly always designed, conducted, and analyzed by people who believe deeply in the power of acupuncture, so the potential for bias to influence the results is pretty great. This is seen in the consistently unreliable data about acupuncture coming from countries with a cultural bias in favor of the practice.5–9
Of course, clinical research incorporates multiple methods for mitigating the impact of such bias, and these can be helpful. Some of them, unfortunately, are very difficult to use in acupuncture studies. Blinding, for example, is difficult to achieve with patients (who can often tell if they are really being stuck with needles or not), and it is impossible to achieve for therapists, who will always know whether they are giving “real” acupuncture treatment or a sham. Since it the demeanor of the therapist can have a significant impact on the patient’s perception of their condition, it can be difficult to trust seemingly positive results from such studies, especially when the outcome measure is something very subjective like pain, nausea, etc.
That said, we do the best we can with the evidence we have, so let’s take a look at an example of the type of research cited to support using acupuncture at GV20.
One study involved giving the common sedative dexmedetomidine, and its reversal agent, under the skin (SQ) at the GV20 location compared with giving these drugs by other routes and in other locations for the purposes of sedating dogs for x-rays.10 This is sometimes called “pharmacoacupuncture,” which seems a bit of a bait-and-switch.
Dogs were randomly assigned to get the sedative, and the reversal agent, in a vein IV), a muscle IM), or under the skin (SQ) at the GV20 point. Sedation was measured by numerous techniques and lots of comparisons were made between the various injection locations.
There were many statistical tests done, most showing no difference form chance and some appearing to. The most consistent finding was that sedation given into a muscle was slower and less effective than sedation given into a vein. Sedation at GV20 appeared to be intermediate between the two, and generally more like IV than IM administration.
The differences were sometimes statistically significant but it is not clear that they were clinically meaningful. The goal (taking orthopedic x-rays) was achievable for all groups, and the adverse effects were minor and not different between the IM and SQ groups (they were greater for the IV group, though none were serious or a reason not to give the sedative by this route if needed).
So what does this have to do with acupuncture? Not much, honestly.
The authors themselves point out that no sedative was given at a SQ spot on the head, or anywhere else, that wasn’t deemed an “acupuncture point.” Perhaps the differences had to do with giving the drug under the skin compared to in a vein or muscle. Or perhaps the head has a particularly good blood supply (scalp wounds are notorious for bleeding profusely), so drugs given SQ here absorb well. There is, in fact, another study comparing administration of sedatives at GV20 and another SQ spot on the head that found not meaningful difference between the locations, so this is quite likely the case.11
There are many plausible explanations for the findings that have nothing to do with the theoretical rationale for acupuncture or the issue of whether or not it works as a general approach. This study doesn’t even convincingly justify the supposed effects of needle stimulation at GV20, much less the larger practice of acupuncture.
Bottom Line Nearly all the studies purporting to validate the benefits of acupuncture at GV20 use injections of drugs or electrical simulation, and none that I have seen effectively control for bias while comparing needling alone at this spot to an appropriate control. Given the implausibility of the traditional explanations for acupuncture, the lack of consistent and convincing evidence that “acupuncture points” exist as a discrete, consistent, identifiable functional entity, and the lack of solid scientific evidence to support the specific claims made about GV20, it is not appropriate to rely on needling at this point as primary component of sedation or pain control for dogs.
As I have said in the past, acupuncture is pretty low-risk in itself, and most of the danger associated with it lies in substituting an ineffective practice for treatments that actually work. If vets want to stick a needle in the head while they also give appropriate science-based treatments for pain, anxiety, and sedation, this is unlikely to do any direct harm. But the belief that this is an “ancient,” Powerful,” or “proven” treatment method is unjustified, and it can lead to unnecessary suffering if we rely on it in place of therapies with better supporting scientific evidence.
References 1. Yang Y, Deng P, Si Y, Xu H, Zhang J, Sun H. Acupuncture at GV20 and ST36 Improves the Recovery of Behavioral Activity in Rats Subjected to Cerebral Ischemia/Reperfusion Injury. Front Behav Neurosci. 2022;16. doi:10.3389/fnbeh.2022.909512
2. Shen EY, Chen FJ, Chen YY, Lin MF. Locating the Acupoint Baihui (GV20) Beneath the Cerebral Cortex with MRI Reconstructed 3D Neuroimages. Evid-Based Complement Altern Med ECAM. 2011;2011:362494. doi:10.1093/ecam/neq047
3. Qian L, Jiang Y, Lin F. Mechanism of the acupoints of the governor vessel in treatment of post-stroke depression on the base of the specificity of meridian points. World J Acupunct – Moxibustion. 2019;29(3):244-248. doi:10.1016/j.wjam.2019.07.004
4. Martha A. Littlefield DVM MS. Anatomic Review of Ten Important Canine Acupuncture Points Located on the Head: Part I. Am J Tradit Chin Vet Med. 2019;14(2):55-66.
5. Wang Y, Wang L, Chai Q, Liu J. Positive Results in Randomized Controlled Trials on Acupuncture Published in Chinese Journals: A Systematic Literature Review. J Altern Complement Med. 2014;20(5):A129-A129. doi:10.1089/acm.2014.5346.abstract
6. Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials. 1998;19(2):159-166. doi:10.1016/s0197-2456(97)00150-5
7. Masuyama S, Yamashita H. Trends and quality of randomized controlled trials on acupuncture conducted in Japan by decade from the 1960s to the 2010s: a systematic review. BMC Complement Med Ther. 2023;23:91. doi:10.1186/s12906-023-03910-3
8. Ma B, Qi G qing, Lin X ting, Wang T, Chen Z min, Yang K hu. Epidemiology, Quality, and Reporting Characteristics of Systematic Reviews of Acupuncture Interventions Published in Chinese Journals. J Altern Complement Med. 2012;18(9):813-817. doi:10.1089/acm.2011.0274
9. Li J, Hui X, Yao L, et al. The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study. BMC Med Res Methodol. 2023;23:96. doi:10.1186/s12874-023-01904-w
10. Leriquier C, Freire M, Llido M, et al. Comparison of sedation with dexmedetomidine/atipamezole administered subcutaneously at GV20 acupuncture point with usual routes of administration in dogs presented for orthopaedic radiographs. J Small Anim Pract. 2023;64(12):759-768. doi:10.1111/jsap.13668
11. Llido M, Leriquier C, Juette T, Benito J, Freire M. Comparison of sedation with dexmedetomidine administered subcutaneously at 2 different locations on the head in dogs. Can Vet J. 2024;65(4):351-358.
Why ask the question? The question implies a conflict, a potential incompatibility. If this doesn’t actually exist, then the subject is moot and we can all go home early.
Proponents of complementary and alternative veterinary medicine (CAVM- also labeled “holistic,” “integrative,” “natural,” and many other terms we will explore shortly) typically claim that science and evidence support their practices. They recognize the marketing value of science, and they often assert that the conflict is a mere misunderstanding, or the result of ignorance, prejudice, or avarice rather than a true conflict between their approach and that of science-based medicine.
For example, the online College of Integrative Veterinary Therapies advertises its curriculum as “a wide range of evidence-based courses…bridging cutting edge science and tradition.”1 A prominent proponent of so-called Traditional Chinese Medicine claims that integrative medicine “provide[s] comprehensive, evidence-based care that integrates the best of conventional and complementary approaches for the well-being of animal patients.”2 You can read journals like Evidence-based Complementary and Alternative Medicine, or articles reporting clinical trials evaluating Reiki, “a biofield therapy currently used in hospitals worldwide [with] scientific evidence [that] supports its effectiveness in addressing many physical and emotional conditions.”3 Even the World Health Organization states that “Evidence-based complementary medicine has the potential to support mainstream medicine and more comprehensively support people’s health and well-being needs.”4
So what’s the problem? Why ask the question at all? Well, the problem is that despite both honest and disingenuous efforts to coopt the language of science and EBM, most of what we typically label CAVM is founded in beliefs and models of nature incompatible with a scientific understanding, and these practices are validated almost entirely by faith, personal experience, cultural tradition, and poor-quality efforts to mimic rigorous scientific investigation. EBM is more than a collection of jargon; it is an approach to knowledge that conflicts directly and forcefully with the philosophy underlying much of CAVM.
Sometimes this divide can be bridged and truly scientific evaluation of CAVM methods can be undertaken. When this happens, the results mostly show these methods don’t work. In the rare cases where they do, they can, and should, simply become part of medicine, stripped of their mystical folk belief systems. In the words of two former editors of the New England Journal of Medicine,
“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.”5
It is instructive to note, though, that proponents of CAVM often object to this type of deep acceptance, arguing it strips away the very core of what make their methods valuable. This illustrates the depth of philosophical incompatibility between science and most of CAVM. As these defenders put it:
“Any CAM practiced its original way cannot be the same as its biomedical version.…If the biomedical paradigm is adopted, the system will have the characteristics of that paradigm- materialistic, mechanistic, reductionistic, linear-causal, and deterministic.”6
“Scientifically constructed ‘evidence’ for an alternative therapy only works when the therapy has mutated into a medicalized version and divested itself of its alternative philosophy. The very publication of trials can act as a reformulation of the very nature of a therapy, generally in the direction of medicalization.”7
The only reason CAVM exists as a category, then, is to highlight the special origins of certain practices as different from those accepted in science-based medicine. This serves both a marketing purpose (selling treatment that is “special” and “different” from conventional medicine) and also as an excuse for utilizing treatments without the type and level of evidence expected for mainstream medicine.
Doctors who would never prescribe a new antibiotic with undisclosed ingredients and no clinical trial data showing safety or efficacy, one that is purported to kill bacteria by targeting its “energy signature,” will happily prescribe herbal or homeopathic remedies with no better evidence. The labels of “natural” or “traditional” are used as excuses to imply safety and effectiveness and evade the normal standards of evidence.
“By definition…complementary and alternative medicine…has 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. Tim Minchin”8
What is CAVM? Before I go further, I should try to define CAVM. This is harder than it sounds because the term encompasses a variety of approaches that conflict with science-based medicine in different ways, to different degrees, and that often conflict just as much with each other. The unity, such as it is, lies not in any shared understanding of nature or of how medical therapies should be validated, though there is some broad agreement on elements of these. The real bond that connects CAVM approaches is their status as “other,” defined in opposition to science-based medicine.
This opposition may be based on conflicting views of nature, competing cultural traditions, or simple part of a promotional strategy to distinguish oneself and one’s practices from other vets and what they offer. The “alternative” in CAVM was the original term for this loose collection of approaches, and it was meant to designate a replacement for conventional, science-based medicine. That proved too much for most human patients, and for most animal owners, who were mostly unwilling to abandon the obviously successful approach that brought us vaccination, antibiotics, and emergency rooms.
This led to the adoption of the term “complementary,” suggesting it was beneficial to use unscientific or unproven practices alongside science-based medicine. This has been more successful, but proponents of CAVM dislike the implication that what they offer is an afterthought or second-rate compared with conventional medicine. This has led to the most successful label; “integrative medicine.”
The idea behind this label is that scientific and alternative therapies are different but equally useful tools available to veterinarians, and each should be used when appropriate without any distinctions based on their underlying theoretical rationales or history. The term suggests we can seamlessly blend alternative and conventional therapies, that they are equally useful and reliable tools we can select from for the medical job at hand.
However, this obscures the reality that there are important practical and philosophical differences between how alternative and conventional therapies are developed, tested, and employed, and these differences matter. Integrative implausible, unproven, or demonstrably ineffective therapies with scientifically validated treatments adds no benefit for the patient, and it can even do harm.
As infectious disease specialist Mark Crislip has put it, somewhat scatologically, “If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.” (for those not familiar with the English idiom “cow pie,” it refers to bovine feces)
The Conflict: Philosophy The core conflict here is philosophical. In terms of epistemology (the science of how we know things), proponents of CAVM largely reject the diagnosis of the disease EBM, and science generally, exists to treat. Forms of evidence viewed as weak and unreliable by EBM are privileged in CAVM, and those types of evidence higher on the pyramid are seen, at best, as nice to have but fundamentally unnecessary to support a given clinical practice. At worst, they reject the very idea that such evidence is more accurate or reliable than personal observation, anecdote, tradition, or pure faith. Science often serves only a marketing function in CAVM, not a meaningful role in choosing and rejecting ideas and practices.
Philosophically, CAVM relies predominantly on trust in personal belief and observation, and in the historical beliefs of individuals or previous generations of folk medicine practitioners. The most extreme proponents reject the hierarchy of evidence behind EBM entirely:
“[EBM] buttresses the idea that there is a legitimate hierarchy of knowledge and method with the [randomized control trial] as the gold standard and the clinician’s notes, observations, and judgments right down there in status with ethnography, sociology and anecdote…there are practitioners of naturopathic modalities who do not subscribe to this hierarchy at all”9
“For ancient and traditional healing modalities, one could argue that history provides the evidence on which to base clinical practice…One cannot conclude that, because a healing system cannot be measured conventionally, it is ineffective or unsafe.”10
“Users of homeopathy did not see a need for scientific testing and were happy with their own judgment of whether the treatment was working for them…[Randomized clinical trials] came at the bottom of their hierarchy of evidence.”7
“The invocation of a saint can cure intractable cancer; a voodoo curse can kill.… A shaman applying a curse does not consider it to be a placebo, nor does his victim. To them, real magic is involved…We can never prove the shaman wrong, only offer an alternative explanation.”6
“As a veterinarian now practicing homeopathy and chiropractic almost exclusively, I have all the proof I need every day in my practice to justify these modalities.”11
Another key source of the incompatibility of CAVM and EBM is the problem of vitalism. At the heart of most alternative approaches, whether explicit or hidden, is a belief that living entities are defined by nonphysical energetic or spiritual forces, and health cannot be maintained or restored by any system that does not account for these forces. Homeopathy, chiropractic, Reiki and other “energy” therapies, traditional Chinese medicine (from which derive most of the forms of acupuncture practiced today), and many other CAVM approaches were born from this pre-scientific belief in spiritual forces as the cause of disease.
While proponents of many of these methods have tried to paint over this idea with more modern scientific language (referencing quantum physics or bioelectricity, for example), the concepts often remain central to their practices.
“Acupuncture reconnects and balances Life energy.… Energy medicines such as homeopathy, homotoxicology, Reiki, craniosacral therapy, and others align the physical, mental, and spiritual portions of the organism. Yes, I did say spiritual and that is a big part of holistic medicine—recognizing the spiritual nature of Life.”12
“pharmacological and surgical approaches appear incomplete…because they ignore the Vital Force which animates and breathes life into the biomachinery of living systems”13
“Because medical science has defined itself on a strictly physical basis, it is true that vitalism is unscientific. By definition, vitalism embraces a concept about a nonphysical force that can never be understood within the current scientific, medical paradigm.”14
“The belief that spiritual, emotional, psychological, or other non-measurable aspects of the individual patient’s presentation are important for healing does not require one to reject evidence obtained from clinical trials, but it does require the recognition that knowledge gained from such methods will be insufficient to guide optimal clinical practice…The importance of Qi in traditional Chinese medicine means that research that cannot and does not account for the force will never be compelling for a practitioner.”15
Even when disavowed, these mysterious forces leave gaps in causal reasoning left unfilled by scientifically legitimate concepts. Chiropractors have largely replace Palmer’s “innate intelligence” with the “vertebral subluxation complex,” but this has not been convincingly shown to exist.16 The “energy” behind Reiki and other supposed energy therapies cannot be detected except by those who already believe in it.17 And for all the thousands of pages devoted to finding a consistent, predictable reason why acupuncture should have beneficial clinical effects, no clear and compelling mechanism has been demonstrated.16 All of these methods, and even some more plausible CAVM practices such as herbal medicine and laser therapy, use scientific language to cover the core principle, which is some undetectable magical force inconsistent with a scientific understanding of physics and biology.
The Conflict: Practice The most unfortunate aspect of CAVM is that it is largely defined and marketed in opposition to science-based medicine. Using it requires at least some level of acceptance of principles and forms of evidence not compatible with an evidence-based approach; and all too often it requires an outright rejection of mainstream medicine.
Use of alternative therapies is associated with less confidence in science-based medicine and less effective use of conventional tests and treatments.18–20 This, in turn, is associated with poorer outcomes, such as shorter survival in cancer patients and greater risk of preventable infectious disease with vaccine refusal. While there is scant evidence to support claims that integrating alternative therapies with scientific medicine improves outcomes, it is clear that it can sometimes worsen them.
Both the growing popularity of alternative treatments and the growing suspicion of science and science-based medicine stem from the same cultural and political factors, issues that have little to do with what is actually best for patients.
Ideally, every idea for assessment and treatment of our patients would go through the necessary steps of scientific evaluation:
development of a biologically plausible theoretical foundation compatible with established knowledge
validation of this foundation and demonstration of possible benefits and risks in pre-clinical research
testing in real-world patients through properly designed, conducted, reported, and replicated clinical trials
Not every step is always possible, and the evidence we have is often flawed and incomplete, for both science-based and alternative medicine. But this path is at least the aspiration of EBM, while is generally not seen as necessary or even desirable for CAVM. While EBM looks forward, developing new interventions and abandoning those that deserve to be left behind, CAVM looks backwards, mining the pre-scientific past for ideas and then setting out to create the impression of modern, scientific legitimacy without a genuine willingness to reject them if the data says we should.
Individual therapies may begin in the CAVM domain and pass into truly evidence-based practice. And some apparently science-based practices may drift into CAVM if evidence develops suggesting they should be abandoned but practitioners are unwilling to do so. However, for the most part CAVM and EBM will remain incompatible, oil and water, interacting but separated by incompatible philosophies, epistemologies, culture and politics, and fundamentally different views of how we should judge our practices.
References
1. College of Integrative Veterinary Therapies. College of Integrative Veterinary Therapies. Accessed October 14, 2025. https://civtedu.org
2. Marsden S. The New Era of Evidence-Based Medicine: Can We Survive It? American College of Veterinary Botanical Medicine Blog. May 11, 2025. Accessed October 14, 2025. https://acvbm.blog/2025/05/11/the-new-era-of-evidence-based-medicine-can-we-survive-it/
3. Barbieri CR. Impact of Distant Reiki on Owner Assessment of Health and Wellbeing of Adult Dogs: A Blinded, Placebo-controlled, Randomized Trial. J Am Holist Vet Med Assoc. 78(Summer):11-19.
4. Traditional, Complementary and Integrative Medicine. Accessed October 14, 2025. https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine
5. Angell M, Kassirer JP. Alternative medicine–the risks of untested and unregulated remedies. N Engl J Med. 1998;339(12):839-841. doi:10.1056/NEJM199809173391210
6. Churchill W. Implications of evidence-based medicine for complementary and alternative medicine. J Chin Med. 1999;59:32-35.
7. Barry CA. The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches. Soc Sci Med 1982. 2006;62(11):2646-2657. doi:10.1016/j.socscimed.2005.11.025
8. Minchin T. Storm. Orion Publishing; 2014.
9. Jagtenberg T, Evans S, Grant A, Howden I, Lewis M, Singer J. Evidence-based medicine and naturopathy. J Altern Complement Med N Y N. 2006;12(3):323-328. doi:10.1089/acm.2006.12.323
10. Curtis P. Evidence-Based Medicine & Complementary & Alternative Therapies. In: Curtis P, Gaylord S, Norton S, eds. The Convergence of Complementary, Alternative, and Conventional Health Care: Educational Resources for Health Professionals. UNC School of Medicine, Program on Integrative Medicine; 2004:Chapel Hill, NC. Accessed October 16, 2025. https://www.med.unc.edu/phyrehab/pim/wp-content/uploads/sites/615/2018/03/Evidence-Based-Med.pdf
11. Jewell G. Comments on practising complementary and alternative modalities. Can Vet J. 2000;41(5):351.
12. Kerns N. Alternative views on canine holistic dog care. Whole Dogs Journal. September 13, 2007. Accessed October 16, 2025. https://www.whole-dog-journal.com/care/alternative-views-on-holistic-dog-care/
13. Stefanatos J. Introduction to bioenergetic medicine. In: Schoen A, Wynn S, eds. Complementary and Alternative Veterinary Medicine: Principles and Practice. Mosby; 1998:227-245.
14. Knueven D. An introduction to holistic medicine. In: The Holistic Health Guide: Natural Care for the Whole Dog.TFH Publications; 2008:9-13.
15. Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Acad Med J Assoc Am Med Coll. 2001;76(12):1213-1220. doi:10.1097/00001888-200112000-00011
16. McKenzie BA. Placebos for Pets?: The Truth About Alternative Medicine in Animals. Ockham Publishing; 2019.
17. Rosa L, Rosa E, Sarner L, Barrett S. A Close Look at Therapeutic Touch. JAMA. 1998;279(13):1005-1010. doi:10.1001/jama.279.13.1005
18. Johnson SB, Park HS, Gross CP, Yu JB. Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers. JAMA Oncol. 2018;4(10). doi:10.1001/jamaoncol.2018.2487
19. Cordonier L, Cafiero F. ?The link between interest in alternative medicine and vaccination coverage?. Rev Eur Sci Soc. 2023;611(1):175-197.
20. Cramer H, Bilc M. Use of complementary medicine and uptake of COVID-19 vaccination among US adults. Front Med. 2025;12:1474914. doi:10.3389/fmed.2025.1474914
I am preparing a series of lectures for an upcoming conference, and it has given me a chance to reflect on some of the core ideas that have always driven this blog– the challenges created by our human limitations and the strategies we have develop to mitigate them.
This lecture attempts to illustrate what evidence-based medicine is and, perhaps more importantly, why we need it. In this current Age of Endarkenment, when science is under attack and misinformation is rampant, such reflection is more important than ever.
Our Shared Malady Evidence-based medicine (EBM) is a treatment for a disease most of us don’t realize we have. It is both a preventative and a treatment, really, but it is not a cure. The best we can hope for is to manage the symptoms and minimize the damage done by our disease.
The disease we suffer from lies in our brains. The mechanisms of observation and judgement we rely on as veterinarians to make recommendations for our patients are riddled with lesions. These have names like confirmation bias, cognitive dissonance, logical fallacy, and many others. The forms and manifestations of our disease are legion.1,2
The consequences of our illness are, sadly, experienced mostly by our patients. Misdiagnosis, overdiagnosis, rejection of effective therapies and use of ineffective ones, and ultimately suffering and death that could, perhaps, be avoided if we sought treatment for our condition.
Like many medicines, EBM, can be bitter and uncomfortable to take. Many of us don’t know we need it, and even when we are diagnosed we may reject the treatment as too unpleasant. And there are potential adverse effects from treatment. A clear understanding of our limitations can be overwhelming, leading to despair and even therapeutic nihilism. However, the potential benefits are great and worth the risks.
Before I describe the treatment, I need to characterize the disease and convince you that you have it. This is especially difficult because the features of our malady include elements specifically inhibiting our ability to recognize it. Confirmation bias blinds us to evidence of our illness. Cognitive dissonance causes pain when we are forced to see and acknowledge such evidence. The Dunning-Kruger effect makes those of us least knowledgeable about the illness feel the most confidence that we are free of it.
The best way to start on our journey may be with a story. Once there was a doctor, a kindly man who cared for children named Dr. Spock. He was an intelligent, caring doctor who brought great progress to the field of pediatrics and parenting. He wrote a book for parents called The Common Sense Book of Baby and Child Care,3 that sold millions of copies, was translated into 29 languages, and became a worldwide guide for parenting.
One key piece of advice Dr. Spock gave parents was that they should always put their babies to sleep on their stomach. Decades of experience, and simple common sense, showed Dr. Spock that doing so would reduce the risk of aspiration if an infant vomited, and this would help prevent Sudden Infant Death Syndrome (SIDS). SIDS is a terrifying and poorly understood condition in which apparently healthy babies die without warning, and parents are desperate for any action they can take to prevent it.
From the publication of Dr. Spock’s in 1946 until the early 1970s, the practice of putting infants to sleep on their stomachs was widely adopted, and parents were reassured by the confident recommendation of their doctors to follow this practice.
However, by the 1970s, abundant research had accumulated showing this practice was a mistake. Babies sleeping on their backs were actually more likely to die of SIDS.4 Despite this evidence, the practice persisted until the early 1990s. For twenty years, parents around the world did the wrong thing, even after science had showed it was wrong, because of cultural inertia, confidence in respected authorities, anecdotal experience, and all the other sources of our confidence in mistaken beliefs.
A review published in 2005 found that heeding the evidence and abandoning the traditional practice sooner might have saved the lives of 10,000 children in the U.K. and 50,000 in Europe, the U.S., and Australasia.4 When educational efforts finally reached parents, and they began putting babies to sleep on their backs, the rate of SIDS dropped markedly.
Figure 1. SIDS rate versus prone sleeping rate in the United States, 1983 to 1995 (from Carroll, 19985)
Does this mean Dr. Spock was a bad doctor? A fool? Were parents around the world stupid? No! This tragedy was a consequence of the illness we all suffer from- a natural tendency to see our personal observations and the stories told by others as compelling and reliable guides to reality, and a lack of a deep, effective appreciation of our limitations and the advantages of scientific data over anecdote and plausible reasoning.
Evidence-based medicine is “the conscientious, explicit, and judicious integration” of controlled research evidence with our clinical expertise and judgement and the goals and values of our clients.6,7 It is not a rejection of the value of the observations and judgements we make, but a recognition of their limitations and the dangers of trusting them too far. It is a set of methods and practices, yes, but first and foremost it is a philosophy, a perspective. “At its heart is the confidence in the scientific methodology that has developed over the centuries to enable us to distinguish what is likely to be true from what is likely to be false.”8 Diagnosing the illness, admitting we have a problem, is the necessary first step for starting treatment. I can teach you a bit about the treatment and how it works, but it won’t help you if you don’t begin by seeing that you need treatment.
Does EBM Work? Proving that EBM is effective is not a simple matter. Where is the completely omniscient and objective observer who can judge that one approach to knowledge is better than another? Who would be willing to admit to practicing opinion-based medicine or belief-based medicine and then be willing to participate in a scientific study to show that their approach is better (or worse) than science?
The best we can do is make some logical inferences, though I personally think these are quite compelling. Consider the change in human life expectancy over time (Fig. 2)
Figure 2. Life expectancy around the world
While this chart starts in the 18th century, the available evidence suggests that the flat line, with overall life expectancy less than 40 years, could be extended many thousands of years into the past. Figure 3 shows a major reason for this, which is the high proportion of human children who did not survive to adulthood for most of human history.
Figure 3. Childhood mortality.
For the vast majority of human history, most humans didn’t survive childhood (or childbirth), and we were plagued with parasites and infectious diseases, malnutrition, and a host of other acute and chronic ills. While a lucky few in each generation managed to live to old age, the great majority could expect only the Hobbesian reality of a “poor, nasty, brutish, and short” life. And then, in a mere handful of centuries, that changed.
Today, we enjoy a length of life and a state of health and wellbeing unimaginable to even the most fortunate of our ancestors. What changed? Did we evolve physically? Did the environment become more hospitable? The gods kinder?
The answer is simple and profound- science. All that changed was our ability to understand nature. Over centuries, we developed the methods of scientific thought and practice that led to a more accurate understanding of the causes of illness and death. And with that improved understanding came both new techniques for treatment and prevention, and also new methods for testing those techniques.
We are using the same brains our ancestors used. In our daily life, including in clinical practice, we still observe and reason as they did, and we make all the same errors. But we defer often enough to the picture of reality built by the community of scientists using scientific methods that we end with better information and making better choices.
EBM is just an extension of this set of methods. The basic steps, and all the detail and nuance embedded in them, are all simply a practical application of the principles and methods of science to clinical practice. Deciding, then, whether EBM is worth using depends largely on deciding whether science is better than the alternatives that preceded it. The alternatives most propose—relying more on clinical experience, tradition, or reasoning from theoretical principles- are the same that guided medicine in all the centuries before the changes in figures 2 and 3 began.
The Basics of EBM The core of EBM in practice is quite simple. It consists of five basic steps-
Ask a question
Locate relevant evidence
Evaluate this evidence
Draw a conclusion
Assign a level of confidence
These steps are repeated as often as necessary until we feel we know enough to take action. They are repeated again whenever we have new questions, new evidence appears, or new action is needed. Entire textbooks have been written to guide us through these steps, but the basic process comes down to this.
The Question The first step is to identify what we need to know to care for a given patient. What tests should we run? What treatment should we use? How can we tell if the treatment is working? What can we tell the owner about risks or prognosis?
The key to getting useful answers from the scientific literature is asking useful questions. They should be specific enough to turn up relevant evidence but not so narrow that we exclude useful information. “Do antibiotics work?” is too broad to be meaningful. “Should we use amoxicillin, cephalexin, or enrofloxacin, for one week or for two weeks, in a 9 year-old neutered male Labrador retriever with an infected laceration from a stick on the front limb?” is not going to turn up many relevant clinical studies. Learning how to organize or ignorance and structure our questions is an EBM skill that can be developed, and there are many resources to support this.
Finding the Evidence Another critical EBM skill is learning how to locate useful evidence. Sources as varied as textbooks, scientific journals, online databases and discussion forums, and even the vet working in the office next door are all available, and they all have their strengths and weaknesses. The best evidence is often the scarcest and hardest to access, while the most convenient sources often come with the greatest limitations. Locating and acquiring evidence requires us to be a bit like a detective or someone on a scavenger hunt, which can be fun but can also take time we don’t have. Building a collection of skills and resources over time can reduce the burden of finding useful evidence.
Evaluating the Evidence It would be ideal if we could simply read a published scientific study or listen to the advice of our colleagues and immediately put the information we find into practice. Unfortunately, not all evidence is equally reliable, and even high-quality data may not apply to the patient in front of us. Critical appraisal of evidence is arguably the most important, and the least used step in this list.
There are shortcuts that can help us. The classic pyramid of evidence in Figure 4 illustrates an approach to evidence that is sophisticated but academic and not always useful in practice.
Figure 4. Traditional evidence pyramid.
I prefer a simpler scheme which is more easily applied for most of us.
Figure 5. Practical evidence pyramid.
This emphasizes that all sources of evidence are potentially useful, but the closer we get to the top of the pyramid, the more confidence we can have in the information. Synthetic resources, such as clinical practice guidelines and systematic reviews, are especially valuable since they are both high in reliability and efficient, requiring less time, effort, and expertise to use effectively.
The Conclusion and the Confidence Once we have gathered the available evidence and evaluated it, our main job is to decide what it means. What actions should we take or avoid based on the evidence? Just as important as the conclusion we reach is the level of confidence we assign to it. If I choose to say, “Here is a powerful therapy which will cure your cat,” that sets up very different expectations and behavior, in the owner and in myself, than if I say, “Here’s a therapy a few people have tried in dogs that might help your cat.” For reasons both practical and ethical, it is crucial that we choose and communicate an appropriate level of confidence for the recommendations we make.
Our disease drives us to have confidence greater than warranted by most of the evidence we are likely to have available. EBM gives us both a warning and some techniques for setting a more appropriate level, which then encourages more truly informed consent from our clients and probably more reasonable expectations and better followup.
The Madness and Wisdom of Crowds Let us end with another story. On a cold Thursday morning in December, 1799, the former president of the United States, George Washington, rode out into the snow to inspect his farmlands.9 He was 68 years old, but strong and healthy for his age. That night he developed a bit of a sore throat, and by a day later he was having a hard time breathing.
Unable to swallow a remedy of vinegar, molasses, and butter due to swelling in his throat, he accepted his doctor’s suggestion to remove a half pint (about 240mls) of blood from his arm. The patient did not improve, and the procedure was repeated several times over the day, with various doctors removing a total of about 3 to 4L of blood (about a third to half of the typical total blood volume for an adult man). Despite these heroic efforts, the former president died after about 13 hours of intensive treatment.
Bloodletting has been a routine and respected therapy in many cultures around the world and in many different historical eras. It is based on a simple powerful idea: What if we all illness stemmed from a derangement of a few essential factors, and we could prevent or cure illness simply by keeping these in balance?
This idea is intuitively appealing, clear, and logical. It is also, of course, wrong. But every time it has emerged, it has captured the imagination and deep faith of the brightest medical and scientific minds, and persisted for centuries, even millennia, and into the present day.
A reasonable catchall name for this view is humorism. It was the rationale for the treatment of bloodletting promoted by Hippocrates in the 5th century BCE and accepted by George Washington’s doctors in 1799. Some versions of humorism persist today in the theories of Traditional Chinese Medicine and Indian Ayurveda.
There have always been skeptics of bloodletting. George Washington’s wife opposed the practice and begged his doctors not to take so much blood from her husband. But the logic of humorism and the innumerable anecdotes of patients cured by the practice overcame such skepticism. As late as 1875, defenders of the practice argued for it with reference to such compelling evidence:
“Who is there with ten or twenty years experience in the profession, that has not seen the most marked advantages from bleeding…” asked one such defender.10 Another learned physician wrote that, “He thought it really saying too much…that we should assume to be so much wiser than our fathers, who had lent their approval to a custom that had been sanctioned by ages of experience.”10
Eventually, the current models of physiology and disease replaced humorism, and the methods of science replaced bloodletting with a range of practices that, while imperfect, have nearly doubled human life expectancy and brought levels of health and comfort unimaginable in most of human history.
So were all our “fathers” bad doctors? Fools? No! This story is meant to show the unique and challenging nature of our disease. It is both congenital, built into each of our brains from birth, and also communicable. The manifestations of this illness in each of us magnifies the symptoms in others, and in a population the disease can make us sicker and do more harm that in one isolated patient. We can reinforce and sustain each other’s beliefs, even if they are egregiously wrong.
Fortunately, the same power of the community lies in the treatment for our illness. Science is a community process in which we pit our limited, imperfect, biased notions against each other in a competition judged by the strength and consistency of the data we can produce. Though the madness of crowds11 can lead us horribly astray, the wisdom of crowds12 can rescue us from our individual delusions. The secret is to harness the competition of ideas in a race governed by the rules and standards of science and evidence.
Evidence-based medicine is a part of the larger project of using science to control our illness, to keep us closer to the truth of nature so we can help our patients most effectively.
Key Points
Human observation and judgement is inherently flawed, and our confidence in our reasoning is typically greater than the true accuracy of our beliefs.
Evidence-based medicine (EBM) is a facet of the greater project of science. It is a set of perspectives and practices meant to improve the accuracy of our understanding of nature and set appropriate degrees of confidence around our beliefs.
The five basic steps of the EBM method are-
Ask a question
Locate relevant evidence
Evaluate this evidence
Draw a conclusion
Assign a level of confidence
This is an iterative process, repeated often as our information needs and the available evidence change.
Groups of humans can strengthen and persist in false beliefs for generations.
Groups of humans can also develop more accurate understanding of nature if guided by the methods of science
Individual clinicians can benefit from EBM by
Maintaining an awareness of our disease and its consequences
Following the steps of EBM
Relying on the work of a scientific community more than on individual personal experience and belief
References 1. Kida T. Don’t Believe Everything You Think. Prometheus; 2006. Accessed October 9, 2025. https://www.simonandschuster.com/books/Dont-Believe-Everything-You-Think/Thomas-E-Kida/9781591024088
2. McKenzie BA. Veterinary clinical decision-making: cognitive biases, external constraints, and strategies for improvement. J Am Vet Med Assoc. 2014;244(3):271-276. doi:10.2460/javma.244.3.271
3. Spock B. The Common Sense Bookf of Baby and Child Care. 1st ed. Duell, Sloan, ad Pearce; 1946.
4. Gilbert R, Salanti G, Harden M, See S. Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. Int J Epidemiol. 2005;34(4):874-887. doi:10.1093/ije/dyi088
5. Carroll JL, Siska ES. SIDS: counseling parents to reduce the risk. Am Fam Physician. 1998;57(7):1566-1572.
6. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. doi:10.1136/bmj.312.7023.71
7. Straus SE, Glasziou P, Richardson WS, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 5th ed. Elsevier; 2019.
9. Vadakan V. The Asphyxiating and Exsanguinating Death of President George Washington. In: 2004. Accessed October 9, 2025. https://www.semanticscholar.org/paper/The-Asphyxiating-and-Exsanguinating-Death-of-George-Vadakan/33f243e97580948b73e700df9489906a37849247
10. McKenzie BA. Placebos for Pets?: The Truth About Alternative Medicine in Animals. Ockham Publishing; 2019.
11. Mackay C. Extraordinary Popular Delusions and the Madness of Crowds. chard Bentley; 1841.
12. Surowiecki J. The Wisdom of Crowds. First Anchor books edition. Anchor Books, a division of Random House, Inc; 2005. Accessed October 9, 2025. http://catdir.loc.gov/catdir/samples/random051/2003070095.html
I was recently privileged to give a brief talk at the Hill’s Global Symposium focusing on aging in veterinary patients. This is a very quick summary of merely one example of how understanding aging mechanisms can create opportunities for developing treatment to give our patients longer, healthier lives.
This article does a good job of articulating the issue with only a bit of the unfortunate false balance so common in media coverage of anti-vaccine activism, alternative medicine, and other extreme viewpoints.
The newspaper also provided a brief guide to vaccination for pet owners which is less detailed than veterinary guidelines (e.g. those from the American Animal Hospital Association for dogs and cats) but which does address some important questions.
Long-time readers will have noticed I haven’t been posting much here lately. Partly, that is due to all the other work I am doing, both in the clinic and as part of the canine aging research I am involved in.
It is also somewhat due to a natural decline in enthusiasm for the game of pseudoscience whack-a-mole, where I try to pre bunk or debunk both the old classics of misinformation and the endless stream of new theories, products, and practices that are foisted upon pet owners with insufficient scientific evidence to justify them. After sixteen years of the blog, my book, and countless articles, interviews, social media posts, etc. on these topics, I have said much of what I have to say many times over.
I’m certainly not giving up, especially since advocacy for science and against pseudoscience and the Age of Endarkenment is more important than ever, given the anti-science madness that has seized our government and so much of the citizenry in the U.S. But detailed evaluations of specific claims and therapies will be less frequent, at least for a while.
In the meantime, I am doing things that might be of interest to some of you, and I thought I’d share the latest of these-
Abstract Frailty is a measure of the net impact of ageing on the health and function of individuals. It is a manifestation of the decline in homeostatic mechanisms that lead to an increased vulnerability to negative health outcomes such as disability, disease and death. Frailty can be quantified through clinical metrology instruments. The most common of these are the frailty phenotype and the frailty index. Both frailty phenotype and frailty index instruments have been developed for use in dogs. The frailty phenotype is a clinical syndrome assessed by the clinician using a small set of measures to classify a patient as normal, pre-frail or frail. These measures typically include assessments of nutritional status, mobility, muscle strength and tolerance for activity. The frailty index uses a deficit accumulation approach, assessing a large number of variables, from historical and physical examination findings to disease diagnoses and clinical laboratory abnormalities, to generate a continuous frailty score. Measuring frailty allows clinicians to stratify patients by level of risk for negative health outcomes. This can aid in guiding diagnostic and treatment intervention, and facilitate making decisions about treatment options.
This is a review article summarizing what we know about frailty in senior dogs- what it is, how to measure it, and what we can use it for. It includes a link to a clinical frailty measurement tool for vets. I have also recently done a live webinar on this topic, which will soon be available on demand at the site of the Senior Dog Veterinary Society.
Abstract Aging is a universal, continuous, and complex process in which an animal’s biological ability to resist, react to, and recover from environmental stressors declines and there is an alteration of physiological processes in response to accumulating cellular damage. In companion dogs and cats, aging is often perceived as an unmodifiable decline in physical and mental capabilities combined with increased morbidity, all aligned with chronological age. An insufficient understanding of healthy aging means missed opportunities to alter the trajectory of health span and maintain overall quality of life despite those changes that are inevitable. We believe that the course of aging is modifiable throughout an individual’s entire life, with healthy, or successful, aging being an achievable goal. We explored herein 3 aspects of healthy aging: the need for a better scientific understanding of aging processes in dogs and cats and practical potential of biological aging clocks; a meaningful definition of healthy aging; and greater use of validated clinical monitoring tools and resources. A universal, meaningful, and actionable definition of healthy aging is needed to dissociate aging from declining health and poor quality of life in all their manifestations. The unique relationship between pets and their caregivers may demand a more expansive definition than that for humans. We propose that healthy aging in dogs and cats should be regarded as aging in which the individual maintains functional capabilities and develops resilience sufficient to meet their own physical, behavioral, social, and emotional needs throughout all adult life stages, while sustaining the human-animal bond.
This is the result of a scientific working group I participated in last year. The goal is to help define healthy aging in dogs and cats and examine some of the main drivers of aging in order to point vets in the direction of better, more proactive management of this critical health issue in our pets.
These are three chapters I contributed to a new book exploring some controversial issues in contemporary veterinary medicine. Several of these are topics I have written about previously, such as over diagnosis and the roles of general practitioners and specialists in patient care. The chapter on how to think about ethical dilemmas in vet med is new, a there is a lot more really interesting content from the other contributing authors and the editors.
I will continue to share my ongoing work in the aging field here, as well as periodically tackling some of the infinite variety of veterinary pseudoscience out there when I can’t help myself. ?
Back in 2016, proponents of using acupuncture in veterinary medicine attempted to gain recognition as a medical specialty through the AVMA’s American Board of Veterinary Specialties (ABVS), which is the organization that formally recognizes such specialized branches of veterinary medicine. The attempt failed because the ABVS recognized there was “a lack of scientific basis for such a specialty.” In other words, as I have been illustrating for over 15 years, there is no compelling body of scientific evidence showing that acupuncture is a coherent, safe, or effective treatment for any medical condition.
I detailed my own training and certification in acupuncture here, and despite engaging deeply with the scientific literature and hands-on practice, I remain unconvinced by claims that this method is anything more than a reliable of pre-scientific folk medicine, especially as taught an practiced by the majority of proponents through the perspective of so-called Traditional Chinese Medicine.
I am by no means alone in my conclusions, and the Evidence-based Veterinary Medicine Association (EBVMA), of which I am a member and past-president, has submitted an official letter recommending again rejecting the petition as inconsistent with the preponderance of the scientific evidence.
I contributed to this letter, but I had a slightly different view of the issues and so have also chosen to submit my own letter to ABVS opposing the petition. I encourage anyone who shares my concern to submit your own letter, or I would be happy to add your name to my own and that of other individuals who have chosen to endorse this statement. I have copied the letter and the current list of individuals endorsing it below. Let me know in the comments if you would like to be included
Public comment on this petition is due no later than 11:59 p.m. on August 12, 2025. All comments must be submitted by email to ABVS@avma.orgwith the subject line “Public comment – Acupuncture Specialty.”
Letter Opposing Recognition of Acupuncture as a Veterinary Medical Specialty
We are writing to oppose the establishment of an ABVS-sanctioned specialty in veterinary acupuncture. A similar petition was denied in 2016 due to “a lack of scientific basis for such a specialty.” Nothing substantive has changed since that decision, and despite decades of research and thousands of studies in humans and other species, there is still no cogent, robust body of scientific evidence to support the claims and practices of acupuncturists.
Acupuncture is fundamentally based not on plausible and proven scientific principles but on pre-scientific folk medicine concepts. The majority of veterinary acupuncture practitioners are trained in the model of so-called Traditional Chinese Veterinary Medicine (TCVM), largely by the Chi Institute and affiliated organizations. This system consists of a mélange of practices and philosophies developed for use in humans and adapted in modern times for use in animals. These disparate folk medicine traditions were repackaged and marketed as a unified system in China in the 1950s for domestic political reasons and then introduced into Europe and the United States in the 1970s.1,2 The claim that acupuncture is an ancient, unbroken tradition of veterinary treatment is not only irrelevant to the scientific validity of the practice but also factually incorrect.
TCVM relies on pre-scientific concepts to guide and validate acupuncture, including manipulation of an undetectable spiritual energy (e.g. Chi) and the Daoist metaphysical concept of “balance” between the universal opposites of Yin and Yang, often identified with masculine/feminine, heat/cold, light/dark, the seasons, and the five “elements” of nature (earth, air, fire, water, and wood).3 This system is similar to ancient Greek humoral medicine, Indian Ayurveda, and many other folk medicine systems for explaining disease in the absence of a scientific understanding of biology. Such a method does not correspond to the reality of physiology and pathophysiology as revealed by science, and it has not place in modern, science-based veterinary medicine.
Some proponents of acupuncture will claim that while they continue to use the terminology and clinical practices of TCVM acupuncture, they have replaced the underlying folk medicine principles with scientific explanations for the effects of their treatments. This often includes claiming acupuncture “points” and “channels” have some identifiable correspondence to verifiable functional or anatomic structures (e.g. nerves, muscles, blood vessels, tendons, myofascial “trigger points,” etc.). Stimulating these locations with needles, and with non-traditional adjuncts like electricity, is claimed to release endorphins or endogenous opioids or have other detectable physiology effects.
The problem with these claims is that they have not been validated by high-quality, repeatable scientific research.4 The minor local trauma of needle insertion certainly has detectable effects, certainly, but the consistency, predictability, and clinical value of these effects has not been demonstrated. There is little to distinguish acupuncture from other forms of mild trauma, such as prodding patients with a toothpick or striking them lightly with a hammer.
Similarly, the existence of special “points” at which such minor trauma should be directed has not been convincingly demonstrated. Almost any part of the body contains some structure that one could argue is relevant and would respond in some way to stimulation. Studies of clinical acupuncture find that different practitioners use very different locations for needling,5 and virtually no part of the body has not been claimed as a special “point” by at least some school of acupuncturists.4,6,7
The lack of a biologically plausible theoretical mechanisms demonstrated by pre-clinical studies for both TCVM and the more ostensibly scientific varieties of veterinary acupuncture is not the only deficiency in the evidence base. Despite the lack of a plausible and demonstrable mechanism of action, many clinical studies of acupuncture have been done, in humans and other species. Even with thousands of such studies, and thousands of systematic reviews and meta-analyses conducted over many decades, no clear consensus has emerged demonstrating meaningful, consistent, predictable benefits for acupuncture treatment. The claims acupuncturists make are still predominantly based on personal clinical experience and selective emphasis on positive clinical studies with significant methodological flaws.
PubMed lists over 2,000 systematic reviews of acupuncture studies since the last attempt to form a veterinary acupuncture specialty in 2016. The vast majority of reviews, and of acupuncture clinical studies, are conducted by advocates for the practice, and many are published in journals and countries with a documented publication bias that favors acupuncture.8–12 Despite this obvious risk of bias, systematic reviews of the systematic reviews in this area consistently find inconclusive evidence or low quality, with the best quality studies most likely to show no effect and the positive studies most likely to involve subjective symptoms, such as pain.
For example, a 2022 review of systematic reviews concluded13,
“Despite a vast number of randomized trials, systematic reviews of acupuncture for adult health conditions have rated only a minority of conclusions as high- or moderate-certainty evidence, and most of these were about comparisons with sham treatment or had conclusions of no benefit of acupuncture.”
This is effectively the same conclusion as a similar review of reviews published in 200614,
“Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication.”
When decades of research involving thousands of studies and hundreds of thousands of participants fail to find unequivocal, high-quality evidence supporting an intervention, it becomes very implausible to claim that it is a powerfully effective treatment that deserves recognition as a medical specialty.
The veterinary acupuncture literature, as expected, is far smaller and or lower quality than the research in humans. The majority of studies have significant methodological limitations and high risk of bias, and both positive and negative results have been reported. The literature is insufficient to support rigorous systematic reviews or meta-analyses. There is little reason, however, to imagine that the results of reviews, even if more and better quality studies were available, would be more supportive than the vast, and still inconclusive literature on acupuncture in humans.
Proponents of a specialty argue that the popularity of the practice is growing and that this justifies a recognized specialty. Even if their claim of 5,000 individuals trained in this practice is correct, that represents less than 4% of veterinarians in the U.S. More importantly, the popularity of a practice has no relevance to its scientific validity.
Recognition of acupuncture as a specialty would create the impression that it is a clinical practice with scientific validity and genuine expertise equivalent to cardiology, internal medicine, emergency and critical care, and other ABVS-recognized specialties. This is simply false. Even if recognition encouraged standardization of training and credentials, how is this of value to veterinary patients and clients when the principles underlying this training are implausible and not supported by reliable and consistent scientific evidence? Legitimizing acupuncture by declaring it a clinical specialty would mislead veterinarians and the public and likely encourage expanded use of this dubious practice. For these reasons, we oppose the current petition.
Brennen McKenzie, MA, MSc, VMD, CVMA
Gary Block DVM, MS, DACVIM President EBVMA
Jörg M. Steiner, med.vet., Dr.med.vet., PhD, DACVIM, DECVIM-CA, AGAF
Nicholas Jenkins, DVM, MS
Erica Tramuta-Drobnis, VMD MPH CPH
Thomas Doker DVM, MPH, DACVPM(Epidemiology), CPH
Robert Larson DVM, PhD, DACT, DACVPM Epidemiology), ACAN
Martin Whitehead BSc, PhD, BVSc, CertSAM, MRCVS
Luis Arroyo Lic. Med Vet,, DVSc, PhD, DACVIM
References
1. Ramey DW, Buell PD. Acupuncture and ‘traditional Chinese medicine’ in the horse. Part 1: A historical overview. Equine Vet Educ. 2004;16(4):218-224. doi:10.1111/j.2042-3292.2004.tb00301.x
2. Michaels PA. Chinese Medicine in Early Communist China, 1945–1963: A Medicine of Revolution. Soc Hist Med. 2006;19(2):338-340. doi:10.1093/shm/hkl010
3. Xie H, Preast V. TCVM: Fundamental Principles. 2nd ed. Chi Institute Press; 2013. https://media.graphassets.com/pp77sBzRQVGnm6lNJa8x
4. McKenzie BA. Acupuncture. In: Placebos for Pets: The Truth about Alternative Medicine in Animals. Ockham Publishing; 2019:490.
5. Molsberger AF, Manickavasagan J, Abholz HH, Maixner WB, Endres HG. Acupuncture points are large fields: the fuzziness of acupuncture point localization by doctors in practice. Eur J Pain Lond Engl. 2012;16(9):1264-1270. doi:10.1002/j.1532-2149.2012.00145.x
6. Magovern P. Koryo Hand Acupuncture: A Versatile and Potent Acupuncture Microsystem. Acupunct Med. 1995;13(1):10-14. doi:10.1136/aim.13.1.10
7. Gori L, Firenzuoli F. Ear Acupuncture in European Traditional Medicine. Evid-Based Complement Altern Med ECAM. 2007;4(Suppl 1):13-16. doi:10.1093/ecam/nem106
8. Li J, Hui X, Yao L, et al. The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study. BMC Med Res Methodol. 2023;23:96. doi:10.1186/s12874-023-01904-w
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Over the more than 15 years I have been writing this blog, I have tried to call attention to some individuals who consistently and egregiously disdain science and offer unfounded, potentially dangerous products or advice. This effort, more than any other aspect of the blog, has generated vehement and voluminous hostile response from the individuals themselves and their supporters.
This system is under-resourced and subject to the whims of politics, and it rarely seems to care about whether vets provide treatment that is safe and effective. Most actions taken by veterinary medical boards or the legal system concern administrative or procedural violations, malfeasance involving money or controlled drugs, or other transgressions that are not related to whether the practices an individual sells or advocates actually work. The legal system is notoriously unable to impose any basic standard of care that relies on science, leaving the public at the mercy of the judgement of individuals vets.
While this may seem appropriate (vets should be, after all, better able to judge the legitimacy of medical therapies than judges and lawyers), it provides not even the most basic guardrails against pseudoscience and nonsense. I often find myself wondering what the point is of licensing veterinarians and having a government-sanctioned monopoly on the practice of veterinary medicine if the government is effectively going to let any quack sell nearly any nonsense they like as “medicine.” How does this protect the public?
In this context, it requires some pretty extreme behavior to draw legal or regulatory sanction, and even then such sanction is rarely focused on the unreasonable practice itself but some technical violation of the laws or regulations. And when such sanctions are applied, they seem to rarely hinder the individual from continuing to practice whatever nonsense they favor.
In the past, I have pointed out that, for example, Gloria Dodd was warned and sanctioned for illegal pseudoscientific practices, yet she continued to offer them until her death, and her company continued to do so for some time after that. Jonathan Nyce defrauded people with a fake cancer cure for pets (along with plenty of other sketchy activities) for many years before finally being sentenced to prison. Eric Weisman has been sanctioned by the boards for medicine, veterinary medicine, and chiropractic in his state over decades, yet he is still offering claims and services on his web site that seem inconsistent with the law.
My point in discussing these individuals and their interactions with the legal and regulatory system, then, is clearly not to stop their activities, since I have no power to do so. I simply want the public to understand how extreme these people are. Contrary to the myth they peddle of malign and well-funded Big Pharma or other entrenched interests persecuting these noble folks, who are just trying to help people and their pets, the reality is that it takes a lot for work for a veterinarian to get even a slap on the wrist in the current regulatory environment. These people flout even the minimal standards that exist, and while they undoubtedly believe they are brave to do so, they are really just reckless and a danger to the public.
The latest examples include one vet I have written about in the past, Jean Dodds, and another I have been aware of but really not written much about, Margo Roman (apart from a short callout in 2010 when she was selling a nude calendar featuring holistic” veterinarians as a way to raise funds for a series of propaganda videos about alternative veterinary medicine).
Margo Roman Dr. Roman is a proponent of many of the standards of alternative medicine- acupuncture, herbs, homeopathy, etc. She has extreme views on vaccines, diet, and plenty of other subjects. Her particular passions seem to be microbiome-based therapies (derived, of course, from her raw-fed, minimally vaccinated, “chemical-free” dogs) and ozone therapy. It is the latter that most recently got her in trouble with the authorities.
Dr. Roman received a two-year suspension of her veterinary license for recommending to her clients the unscientific and illegal use of ozone to prevent or cure COVID-19. A court decision upheld that sanction. This may seem a drastic action relative to the violation, though it did constitute practicing human medicine without a license, which the government tends to take a bit ore seriously than violations concerning animal patients. However, some investigative reporting has identified a pattern of blatant and egregious behavior that may explain the suspension in this case.
According to this report, has repeatedly been found to have practiced unscientific and ineffective medicine leading to serious patient harm and suffering. A Golden retriever named Lily, who was dying of cancer, was left to suffer after she talked the owners out of euthanasia and employed homeopathy, acupuncture, ozone, and other worthless interventions that clearly had no effect. Another dog was put through a painful dental procedure, with Dr. Roman reportedly filing down many of its teeth and providing no pain control or antibiotics.
She has also been involved in legal action with Tufts University after taking her horse to the veterinary hospital and then refusing to pay for services because the staff was honest about the fact that her alternative therapies were not helping the horse and that the it was suffering. Later she was barred from attending an educational event at the school, which she apparently wanted to attend to challenge the stance of the talk opposing raw diets, since she had refused to pay her bill. The court found her lawsuit in response to be without merit.
Of course, Dr. Roman and her supporters are portraying her as a victim, harassed by entrenched interests that are threatened by her alternative methods. The real victims, however, are the patients she has treated with these methods and their human families, whether they know it or not.
Jean Dodds The other veterinarian recently sanctioned will be much more familiar to readers. Jean Dodds has consistently refused to accept the scientific reality that much of what she advocates is unproven or worthless, such as her Nutriscan allergy testing. She also repeatedly refuses to accept that the government has an authority over what she does as a vet. Despite not having a license to practice veterinary medicine, she offers diagnostic and treatment advice based on the Nutriscan test, and as a result she was cited by the California Veterinary Medical Board for unlicensed practice in 2021. She has continued to do so anyway, and last month she was again cited for unlicensed practice.
The arrogance of not only inventing and selling pseudoscientific tests and treatments but of ignoring the fact that doing so is clearly illegal is really quite stunning. Sadly, when reporting on her 2021 citation I said,
I am not sanguine that there will be any significant consequences for Dr. Dodds stemming from this action…I will not be at all surprised if Dr. Dodds manages to evade responsibility and continue her practices regardless of this action.
Looks like I was right then, and I see little hope that the lates slap on the wrist will change Dr. Dodds’ behavior or shake the confidence of her followers.
A while back I had an enjoyable conversation with Dr. Hubert Hiemstra, who runs the Vet Vault podcast on the Sunshine Coast of Australia. We talked about the changing landscape of veterinary medicine, including economics and science, as well as some of my favorite topics in skepticism, critical thinking, and science-based veterinary medicine. Enjoy!
