The following is a post I contributed to the Science-Based Medicine blog.
On this site there have been several thoughtful posts (e.g. by Dr. Atwood and by Dr. Novella), and subsequently much heated commentary, on the distinction between Evidence-Based Medicine (EBM) and Science-Based Medicine (SBM). I agree wholeheartedly with the position that the two are not mutually exclusive, and that SBM is essentially EBM as it should be practiced, with a comprehensive consideration of all relevant evidence, including the subject of plausibility. As a practicing veterinarian, and an officer of the Evidence-Based Veterinary Medicine Association (EBVMA), I am keenly interested in bringing to my profession a greater reliance on high quality research evidence and sound scientific judgment, and reducing the reliance on individual practitioner intuition and experience in making clinical decisions. However, those of us in veterinary medicine face some special challenges which make the subtle but important distinction between EBM and SBM especially salient.
Where’s the Evidence?
The first of these challenges is the paucity of high quality clinical research evidence. As an example, in his 2007 book Snake Oil Science, R. Barker Bausell examined the research evidence concerning the use of glucosamine as a treatment for osteoarthritis in humans. He was able to analyze the strengths and weaknesses of a Cochrane Review which included 20 studies with 2570 patients (the most recent revision of this review includes 25 studies with 4963 patients), a NEJM study with 1583 patients, and an Annals of Internal Medicine study with 222 patients treated for two years. His conclusion was that the intervention was not more effective than placebo.
I recently did a targeted search of the PubMed literature database for a brief evidence-based medicine feature on the subject of glucosamine and chondroitin as treatment for osteoarthritis in dogs, currently in press at the Journal of the American Veterinary Medical Association. A search of the terms “glucosamine,” “arthritis,” and “dog” yielded eight references, of which three were relevant (a more comprehensive search strategy yielded sixteen references, but only the same three were relevant to the clinical question). The three useful references included two clinical trials involving a total of 113 dogs and each lasting about 2 months, and a systematic review of treatments for canine osteoarthritis which evaluated one of these two clinical studies. Predictably, the larger, better designed trial with objective measurement criteria showed no benefit of glucosamine, while the smaller, less well-controlled trial with only subjective criteria and a 23% dropout rate in the glucosamine group showed some benefit at some assessment points.
Where’s the Money?
Glucosamine is an extremely popular, and profitable, supplement routinely recommended by veterinarians and administered by owners to their geriatric dogs. Yet the clinical trial evidence concerning its effects is nearly non-existent. The depth of the evidence is no better for many, many routine clinical interventions in veterinary medicine. The primary reason for this is simple: money.
Obviously, the health of companion animals is not as high a societal priority as human health. Many countries have little or no formal companion animal medicine at all, of course, much less high quality, evidence-based pet medicine. And even in the developed world, the absolute size of the veterinary medical profession and associated industries is dwarfed by that of the human medical industry.
In the United States, surveys show that most dog and cat owners have come to consider their pets to be members of their family, and their willingness to pay for veterinary care has increased along with this shift in attitude. The same appears to be the case in Europe and other developed nations. This has allowed the quality and technological sophistication of veterinary care to increase.
Pharmaceutical companies have followed this trend, increasing their financial investment in their own internal research activities, as well as funding the lion’s share of companion animal health research generally (with all the ethical and practical problems that creates). Pfizer, the largest fish in the “Big Pharma” pond, claims to spend $300 million annually on veterinary research globally, for both companion and agricultural animals. However, the company is expected to spend $9-$9.6 billion this year on its human research and development. The same pattern is true of government research spending. Veterinary medicine will always be the poor stepchild of medicine, and we cannot expect to have anything close to the quantity or quality of research evidence available to MDs trying to practice evidence-based medicine.
A Pack of Lone Wolves?
Another barrier to effective utilization of research evidence in veterinary medicine may be demographic and cultural. In the United States, the average veterinary practice has fewer than three veterinarians, and between one-third and one-half of veterinarians are self-employed practice owners. And most companion animal veterinarians are general practitioners, only about 10-15% of practicing vets being board-certified, with the extended academic training and, hopefully, greater awareness of and respect for research evidence that might be expected to come from this training.
As a profession, we veterinarians tend to be entrepreneurial, self-reliant, and independent. This contributes to a reluctance to let anyone tell us what to do, which may be how veterinarians perceive the position of evidence-based medicine. There is no solid data on the subject (though I am involved in a survey study which will hopefully provide some soon), but in discussions with colleagues I have sensed a great deal of anxiety about the notion of “cookbook medicine” which disdains the hard-won wisdom and experience of the individual clinician. Veterinarians are reluctant to accept the idea that there may be broadly applicable standards of care they ought to adhere to, even if their personal judgment conflicts with the evidence for these.
Undoubtedly, our colleagues in human medicine share a similar temperament and similar sorts of anxieties about “cookbook medicine”. However, these may be tempered to some extent by more widespread advanced training, more structured and supervised practice environments, and greater assessment and monitoring of outcomes, which may partially explain the greater acceptance of EBM in the human medical profession. And though the case of Dr. Rolando Arafiles, Jr. illustrates the weaknesses in the systems for monitoring physician behavior, I think it is clear that the influence of government regulation, and the threat of litigation, give the concept of adhering to a recognized medical standard of care far greater teeth in the field of human medicine than it has in veterinary medicine.
SBM, EBM, or OBM?
So how does this relate to the difference between SBM and EBM? Well, traditionally the scarcity of clinical trial evidence has led veterinarians to practice primarily opinion-based medicine. Personal experience and intuition and the opinions of individual experts or mentors are the predominant foundations for clinical decision-making. There is little or no outcome assessment, so veterinarians must rely on their own clinical experience to judge whether their practices are effective.
The negative consequences of these strategies are many. There is dramatic inconsistency in the diagnosis and treatment of even common diseases. I routinely have to explain to my clients that if they ask ten vets a question, they are likely to get seven or eight different answers. You can imagine how frustrating this is for them, and how little confidence it inspires in our expertise.
OBM Leads Kids to the Hard Stuff, FBM!
As most readers of this blog likely already know, there are many reasons why individual judgment is an unreliable guide to the true efficacy of a medical intervention, and why we should be reticent to entirely trust our own intuitions and experience. But opinion-based medicine is also a “gateway drug” to faith-based medicine, otherwise known as complementary or alternative medicine. If you are accustomed to judging the safety and efficacy of interventions on the basis of the cases you have seen personally or the opinions of “experts,” you are more likely to be persuaded by the individual experiences of clinicians promoting and alternative practice, and more likely to think that giving it a try yourself is the most reliable way to know if it really works or not.
The Internet abounds with holistic veterinarians who claim they started their careers as scientific, skeptical doctors but that their frustration with the limitations of mainstream medicine and the problems they could not solve led them to experiment with, and ultimately become promoters of, faith-based miracle therapies of every kind that share no theoretical or practical features in common other than being validated primarily by testimonial and not consistent with scientific knowledge or evidence.
Tooth Fairy Science exists in veterinary medicine, but it is less of a problem than the simple lack of research evidence and the consequent reliance on even less trustworthy forms of evidence. So veterinary medicine needs a science-based approach even more desperately than human medicine because we have so little clinical trial evidence to rely on, and so few resources to generate more and better evidence. The tragedy of money and talent wasted on studying therapies that have vitalist theoretical foundations inconsistent with established scientific knowledge is even more poignant in the relatively impoverished world of companion animal medical research. Plausibility must play an important role in deciding how we allocate the scarce resources we have in order to maximize the useful information we can generate, and the subsequent clinical benefits for our patients.
Towards a One Health Approach
Veterinarians must also take advantage of the evidence that our colleagues in human medicine have generated for us. There are serious dangers in extrapolating research evidence across species, of course, but we cannot afford to entirely ignore the wealth of human medical research that is relevant to our patients. Examined cautiously and judiciously, this data can help us target our own research efforts more efficiently. Just as animal models have an important role, despite their limitations, in human health research, so human clinical research can inform veterinary medicine. As clinicians, we can make more science-based decisions, even when relevant veterinary research is lacking, if we are aware of the research in humans that already exists on the conditions and interventions we are considering.
If glucosamine is shown to be no more than a placebo after years of research in thousands of people, how much money and effort should we invest in studying its effects in dogs? And how strongly should we promote it to our clients, the vast majority of whom must pay for their pet’s care out of pocket, without insurance coverage, and who commonly must eschew needed care or even euthanize their companions for want of money to pay medical costs?
A Worthy Goal
There has been a steady growth in the quality and sophistication of care available to companion animals in the last several decades, and I am hopeful that this will continue. But I believe the interests of our patients and clients will be best served if the care we provide is as soundly science-based as possible. And while I think evidence-based medicine can become the standard in the veterinary field, with beneficial effects on the quality of the care we provide, we need the additional features of the science-based medicine approach even more than our MD colleagues: a respect for the importance of plausibility in allocating research resources and an understanding of the need to integrate all relevant evidence when making clinical decisions about interventions in the face of a scarcity of high quality clinical trial research.
Despite all the histrionic accusations of some alternative medicine advocates about mainstream veterinarians being tools of the pharmaceutical industry or reluctant to accept unconventional approaches only out of closed-minded prejudice or a fear for our income, the reality is that we care deeply for our patients and want to provide them with the best care we can. I truly believe, and I hope the profession as a whole will come to accept, that science-based medicine is far more likely to help us do so than the opinion-based medicine we have traditionally relied on.
An excellent post that gets to the heart of the problems of promoting science based veterinary medicine. I think maybe another result of reliance on opinion based medicine is the desire to sound authoritative in front of clients. Sometimes this can result in giving clients information that is demonstrably wrong. Unfortunately, the client often has no way to evaluate which of multiple opinions is most likely to be correct other than how confidently they are presented by the veterinarian. On occasion I have had to pull out textbooks and papers to demonstrate why I think another opinion is incorrect, even when the given opinion was clearly erroneous and a few seconds of thought or checking a reference would have shown it to be so. These situations are uncomfortable for the client and sometimes dangerous for the animal. More scientific and evidence-based practice would probably help to reduce this type of ego-motivated opinion based practice.
Yes, one of the most frustrating things about our profession is that clients have no way to judge our true competence, only the rapport we establish with them. I once had a boss who was a terrible veterinarian, but much loved by his clients for his reassuring, grandfatherly manner. Likewise, I’ve seen colleagues who took excellent care of their patients yet were generally disliked and mistrusted by clients due to their less effective people skills.
So if vets give inconsistent advice, the advice of the more likeable doctor is what will probably be believed regardless of what is correct.
Yes, one of the most frustrating things about our profession is that clients have no way to judge our true competence,>>>>>
Whose fault is that?
see
http://www.ebvet.com/forum/viewtopic.php?f=13&t=176
@art;
Veterinary associations, and vet schools, and state boards certainly bear some responsibility for allowing non-evidence based CAM to flourish and attain apparent respectability in the profession, but I was thinking more about basic competence. I have seen clients who were told that “heat stroke has no effect on the kidneys” for example. A statement like that shows a marked ignorance of the pathophysiology of heatstroke that could be corrected by cracking a book for a minute or two, but is not something many clients can evaluate without a little knowledge of biology at least.
This seems to be a more basic problem than institutionalization of CAM. As Skeptvet points out, clients often judge competence based on personality, and the isolated nature of many veterinary practices allows too many of us to get away with an act that imitates competence. It is hard to admit you need to look something up, or a referral might be better for the patient, but that is often the best thing for the patient. In human medicine, there are often several professionally trained personnel involved with the patient at the same time, which provides some level of safety if someone makes a mistake, while often the veterinarian is the only professional involved in a case-often assistants and techs are trained in-house and don’t have anything to relate to other than their employer’s views.
Anyway, this has turned into a long comment, and my point is that the nature of veterinary practice leaves us open to problems that are more basic than organized veterinary medicine condoning CAM.
but I was thinking more about basic competence.>>>>>
that gets back to how to measure if the basic problem is these doctors who have been through medical training believe in what they are doing or just believe they can make money doing it. How much more medical training do you need to convince doctors who promote selling water as medicine to get them to stop it? Do we need more training does the public need to be convinced its fraud and theft by deception on the part of the Veterinarians marketing treatments that they know do not work?
see
http://www.ebvet.com/article8.php
I think we basically agree that both the support of CAM by organized veterinary medicine and issues of competence are problems. As we have discussed before, reading a veterinarian’s mind to determine if they are a true believer or a con artist is just about impossible. I think that the nature of veterinary medicine and the general lack of critical thinking skill it engenders means that many, probably most, veterinarians who use CAM fall more toward the believer side, even though it seems hard to believe at times.
What I am trying to say is that better critical thinking skills and understanding of cognitive biases would probably help to reduce both the use of CAM and ego/opinion based medicine that is not CAM, but just wrong. If you realize that memory is imperfect, and that checking references from time to time is not a weakness, you are more likely to avoid both quackery and also ordinary mistakes.
At the risk of being banned from the blog, I have to say, I simply agree with Art’s one-liner…who’s fault is that? But, perhaps not specifically for the same reasons he outlined in the linked post.
I’ve often asked of the vets here why they don’t stand up for EBM, SBM or whatever you choose to call it, with your clients. After all, it is the client you must convince, not the pet. It is the appointment with your client that is your first line of defense against CAM.
It’s been said that you do not wish to alienate your clients (or you care not to delve into their psyche as to why they believe and request CAM in the first place), yet you are essentially alienating them by not discussing the merits of science you wish to practice. That’s not an opinion on your part, it’s presenting facts and giving them resources in which to back up your facts. You shouldn’t have to placate the client, you’re not treating the client, you’re treating the pet who is depending on your sound knowledge and expertise. I realize the difficulty, but perhaps less placating the client and more focusing on the pet’s needs, being consistent and showing them results will help the client in the end.
It is also the client who has been prior misled and is now demanding CAM. You have the option to deny such requests and replace that misinformation with useful information. Will it hurt your practice? I think losing a few wayward clients is worth staking your reputation for those clients (as well as your colleagues) who appreciate your EBM-practice.
Totally off-topic but how about the medical marijuana fiasco as an example? Respectable MD’s don’t want traveling clinics and doctors who see 300 patients a day with little attention to that doctor-patient relationship and without a complete evaluation of the patient’s health history. So, the state medical board can and does halt the practice, and those “patients” wanting the MM must find other ways to get it, through an MD who will prescribe it ethically and utilize a legal route to dispense it. I realize one cannot compare MM with CAM, but it essentially has the same problems and loopholes.
Why isn’t the veterinary profession following the same lead? Why aren’t you working for, and demanding the same regulations through your state boards and legislators? My guess is that ego-thing, you don’t want to step on another vet’s toes, you don’t want to alienate colleagues, but this problem isn’t going to go away anytime soon unless vets speak out and want change. The CAM amendments in the AVMA for example, an initially small group of concerned vets and other health care professionals were concerned enough to garner support from others and
do something about it.
Bartimaeus, I like you. But, I do not agree with your statement that vet assistants and techs often don’t have anything to relate to other than their employer’s views. Having worked for a number of vets, I personally never blindly followed a view I was uncertain of without investigating it myself. Techs have a great many resources to evaluate information than they did a decade ago, but this area too requires a change in critical thinking skills for some. The CAM section for techs on VIN is a perfect example, it’s pretty darn scary and it doesn’t look like anyone is stepping in to curb all the misinformation. I think that’s a blatant oversight on someone’s part if not many.
The CAM section for techs on VIN is a perfect example, it’s pretty darn scary and it doesn’t look like anyone is stepping in to curb all the misinformation. >>>>
Science based veterinarians have tried and got kicked off VIN. Here is a post on vin from a scienced based vet Bob Imrie in a dialog with Paul Pion the owner/president of VIN.com
Robert Imrie on 03/30/2004 0:51:32 am ET
“I’ve been a VINner for six or seven years now, and though I’ve had to “grin and bear it” as you’ve likened me, personally, to Joseph McCarthy and have referred (privately) to me as an “emotional terrorist” for daring to post high-quality scientific references that refute the specific claims of VIN alt med “experts,” I don’t believe I’ve ever seen or heard you take advocates of such therapies – or anyone else on the VIN alt med boards – to task in any serious way for promoting either demonstrably false or grossly misleading “alternative” therapeutic claims.
I confess that I never dreamt that doing what the Veterinarian’s Oath obliged me to do 30 years ago would ever make me subject to the vicious verbal abuse I’ve received from VIN-subscribing veterinarians and “experts” who’re proponents of unscientific, unproven and disproved therapeutic claims that presumably swore to uphold exactly the same oath that I swore to uphold! Perhaps I shouldn’t have been surprised by it, but the additional abuse and censure I’ve had to put up with from VIN “powers that be,” has constituted – in my view — “insult added to injury.”
While – in view of your obvious personal prejudices, and the (presumable) fact that you must be under overwhelming pressure from VIN alt med “true believers” to have me kicked off VIN – or at least off the alt med message boards — you have – so far – refrained from doing so. While I find much to criticize with regard to your handling of these issues, I have to at least offer you the begrudging and highly provisional complement that “at least you haven’t given me the axe yet.” Of course, as Scarlet O’Hara observed, “tomorrow is another day.”
Robert Imrie, DVM
Thanks for that, Art. I miss Bob 🙁
@v.t. I did not mean to suggest that all veterinary assistants/techs are so inclined, but in my area, and many other small towns/rural areas, many of them are trained on the job and often have no other formal training to compare what their employer is telling them with. They often are not provided with any CE or other resources by their employers either. Some vets actively discourage any questioning of their ideas. There are certainly exceptions to this, and the problem may not be as widespread as my personal experiences might indicate.
I agree that this is the fault of the veterinarians at question, not the assistants/techs, and my point was more that a veterinarian who does not want to think critically about his or her practice and knowledge can create an environment where he is seldom challenged. Perhaps the CAM section of VIN is another example of this on a larger scale. At any rate, my comment was not meant as a reflection on the many well trained and competent techs that do exist out there, and there is more opportunity now than in the past for self education.
Personally I was quite dissatisfied with VIN and canceled my membership after letting the management know why. I believe David Ramey was asked to leave VIN after questioning the experts as well. I suspect that some of the management of VIN are possibly somewhat of believers, if not in CAM then in the money associated with CAM. This is another aspect of the institutionalization of CAM that bothers all of us in this discussion. The financial aspects of CAM in veterinary medicine and the related politics are a complex issue, and there are very few voices speaking out against it at this point, so we are easy to ignore. At the last big veterinary conference I was at, I had a discussion with two old classmates who I consider friends, but apparently politely questioning the efficacy of acupuncture offended them and I haven’t heard from them since. That does not mean I will quit speaking out, but at this point the science and evidence based veterinary community is fairly easy to ignore when desired.
Bartimaeus, thank you for taking the time to explain in greater detail, I appreciate it. I still like you 🙂
And you’re right, I’m not naive to believe my little neck of the woods is special, nor am I, but just wanted to share that there ARE indeed EBM, SBM-minded, critical thinking techs out there! The VIN section for techs I mentioned was just an example of how far out there things can get though, without any supervision, challenge, oversight. To hear them, you would think they were practicing without their employers’ knowledge, now that’s a scary thought.
I believe David Ramey was asked to leave VIN >>>>>
That does not surprise me but I cannot find any of Dr Ramey’s post about that in my files. Some science based reporter needs to develop a list of SBM/EBM vets who were kicked off VIN and interview them about getting the boot from Paul Pion before they all die.
I think he mentioned it on the altvetskept listserv a while back when The Skept Vet was having a discussion with Dr. Pion about stem cell therapies.
Some science based reporter needs to develop a list of SBM/EBM vets who were kicked off the Altvetskept list and interview them about getting the boot from Philip Johnson before they all die.
see
Subj: Altvetskept list
Date: 11/13/02 10:56:12 AM Eastern Standard Time
From: johnsonpj@missouri.edu
To: artjamie@aol.com
Sent from the Internet (Details)
Dear
The altvetskept list was conceived and is maintained by members of the
veterinary medical Profession. Although the list is “open” to ANYONE for
discussion pertaining to the SUBJECT NATURE for which the list was set up,
we are not prepared to tolerate irrelevant and on-going posts of a nature
that is unnecessarily abusive to either our profession or other members of
the list.
You have repeatedly used our list to make your point about vaccines,
however, you have also used the list as a forum to make unsubstantiated and
abusive allegations about members of the veterinary profession. In
addition, you have elected to ignore specific requests to elucidate your
positions and/or for evidence to support your allegations.
One of the primary goals of this list has been and continues to be to
emphasize that medical/veterinary medical “claims” are well supported by
evidence and that those people making “claims” should be required to called
to task to support them (and not simply ignore requests for specific
clarification). This can be done without resorting to attacks on your
colleagues, and without repetitive posts about what you feel list members
should or should not do. Please advise if you are prepared to submit your
posts for review prior to seeing them on the list for a probationary period,
otherwise, we appreciate your interest but regret that you cannot abide by
rules of list decorum.
Sincerely,
Philip Johnson
On behalf of the
Management of the ALTVETSKEPT-LIST
Art Malernee dvm
fla lic 1820
art malernee dvm says:
Your comment is awaiting moderation.
August 3, 2010 at 4:44 am
if the Aug3 post of mine does not pass moderation in the next few days those wanting to read what I posted can find it on this webpage using the google Sidewiki software
see
http://www.google.com/sidewiki/intl/en/index-chrome.html#tbbrand=
art malernee dvm
fla lic 1820
Sorry I haven’t been involved much in this discussion. I’ve been out of town and (gasp!) without Internet access for the last week.
v.t.,
I think there is a big problem with the vet profession no challenging the legitimacy of CAM. I have plenty of theories about why, but I don’t have any real data, and I doubt there is a single, simple answer. On an individual level, many vets are neutral on the merits of the approaches, taking the all-too-common “Well, it might or might not work but at least it’s harmless” attitude. They are simply too overwhelmed, apathetic, or lazy to look into whether or not their assumptions about safetu and possible efficacy are true.
And, as you say, explaining to a client why chiropractic is not going to help their dog when the client uses it themselves and believes it works is an unpleasant task. I have such conversations with clients every day, but I understand why other vets may simply find it too uncomfortable or draining to tilt at the windmills I have chosen to battle.
As a profession, our lobbies and organizations, particularly the AVMA, don’t have the will or the motivation to try and supervise in any way the scientific legitimacy of the therapies individual doctors employ. For one thing, there are enough believers and fence sitters that as a practical matter you could never push through any policies with teeth on CAM therapies. And ultimately, AVMA is more concerned with protecting the profession’s turf than getting involved in controversial campaigns against CAM. And let’s not forget what happened to the AMA when they took on the chiropractors decades ago-a stiging defeat in a restraint-of-trade lawsuit that sucked the force right out of any notion that doctors’ organizations could try to control what was or was not considered legitimate medicine.
Art would undoubtedly say simple greed is another factor, and I can’t say he’s wrong, though I’m not convinced it’s as powerful or pervasive motive for not challenging CAM as some of the others.
Art would undoubtedly say simple greed is another factor, and I can’t say he’s wrong, though I’m not convinced it’s as powerful or pervasive motive for not challenging CAM as some of the others.>>>>
What we need is a online BS meter so we can tell who is really BS-ing who.
Paul Pion on 04/30/2002 10:50:47 am ET Art,Here you go again — full of BS —
art malernee dvm
fla lic 1820
Greetings I stumbled on your blog by mistake when i was searching Live search for this concern, I need to tell you your website is quite useful I also seriously like the design, it is great!
I would like to know what happened to Dr. Bob Imrie. I worked with him when he was a DVM at a clinic in Downey, California back in 1975. We were on and off again in touch when he moved to Seattle. Just saw that he passed away in 2006. Please let me know. Thank you very much, Sergio E. Gonzalez Firefighter/Paramedic Los Angeles County Fire Dept.
I’m afraid I neve met Dr. Imrie and did not know him personally, so I don’t have any additional information to share.
Sergio Gonzalez,
Yes, sadly Dr Imrie passed away, I believe from complications of diabetes. At the time, he was actively engaged in his co-partnership of The Veterinary Task Force with Dr. David Ramey. He was also active with the NCAHF and other skeptic organizations, busy with writing, presentations, etc. I believe he was also a relief veterinarian in Seattle for some time. He and his contributions to fighting quackery are sorely missed.