A couple of years ago, I conducted a small pilot survey of veterinarians to investigate their attitudes and knowledge concerning evidence-based medicine (EBM). While not a representative sample of the profession, the survey identified some interesting issues worthy of further investigation. While respondents were generally very positive about the idea of evidence-based medicine, they generally had little knowledge or training in EBM methods. Many practitioners felt that research information was potentially useful in general practice but was overwhelming in quantity and difficult to access of interpret in an efficient, timely manner. A recent qualitative survey of decision-making processes used by veterinarians in Belgium also found that few were applying EBM methods to their clinical practice.
Vandeweerd JM, Vandeweerd S, Gustin C, Keesemaecker G, Cambier C, Clegg P, Saegerman C, Reda A, Perrenoud P, Gustin P. Understanding veterinary practitioners’ decision-making process: implications for veterinary medical education. J Vet Med Educ. 2012 Summer;39(2):142-51.
Over two-hundred veterinarians were interviewed by telephone, and a small number (31) were interviewed in person. The authors major conclusions were these:
First, veterinarians in this population were far from applying the principles of EBM…The results of this study showed that the EBM approach (asking questions, searching the literature, critically appraising the internal validity of the identified publications, assessing the external validity of the scientific information) was rarely used to inform decisions.
In this study, veterinarians preferred colleagues, the Internet, and textbooks to peer-reviewed journals and literature searches.
This study suggests that veterinarians also use two modalities of decision making: either by (1) recognizing the similarity to a past situation or (2) choosing the most likely solution among a list of possible options, sometimes excluding options in a hypothetico-deductive approach, sometimes proceeding by trial and error.
The study also identified several pragmatic factors that strongly influenced veterinarians’ decision-making. One was time. Veterinarians reported the perception that clinical decisions must generally be made quickly, and that the time needed to employ EBM methods might be incompatible with the demands of private practice.
Another factor was the perception that a methodical, rigorous scientific approach might not satisfy clients. As the authors reported, “[Respondents] perceived that owners want to see immediate action, which does not allow any delay in decision making; as one participant stated, ‘If I am called, it is to give an answer to the owner. It is not possible to say or do nothing, even if you are not sure. Owners request an action.”
Such concerns about the time required to make proper use of scientific research results in formulating decisions and the perceived antipathy of owners to delay or uncertainty are certainly real issues veterinarians must face. Unfortunately, they can easily lead away from a rational, thoughtful science-based approach to clinical decision making and favor a more reflexive, automatic, and opinion-based strategy, which is less likely to lead to the best results.
The study authors make a number of reasonable suggestions for improving the usefulness of EBM to veterinarians. The obvious first step is to improve the quantity and quality of scientific research information in the field. Then it is necessary to make this information available to ordinary practitioners in a clear and simple form that can be applied to the needs of specific patients with minimal time and effort. And veterinary students should be trained in the methods and benefits of epidemiology and an EBM approach and reminded of the weaknesses of informal and unstructured decision-making based primarily on experience and opinion.
The study authors conclude, quite reasonably:
Veterinarians make decisions in a complex environment, often quickly and rarely with an EBM approach. Obviously, this cannot mean that most practitioners make poorly
informed decisions…Two separate worlds seem to exist, academic research and the reality of practice, that need to join, probably by making the effort to include data from practice into research. Both worlds should also meet more in the field of education, where students should be trained in the complexity of contextualized decision making. More important, aside from those efforts to facilitate the development of evidence-based, accountable, and transparent veterinary medicine, there should be initiatives to scientifically demonstrate the benefits of an EBM approach for animals and owners, which would probably facilitate its adoption by veterinary practitioners.
Adequate information and EBM tools are needed to optimize the time spent in query and assessment of scientific information, and practitioners need to be trained in their use.
How many vets attended the EBVMA conference? The EBVMA thread on VIN.com seems mostly you and Paul. I think a lot of doctors both for human and animals would practice evidence based medicine if they could make a living doing it. Its a lot easier for me to preach evidence based medicine than practice it. I have noticed when my veterinary friends retire they seem to suddenly get EBM or are at least willing to listen.
art malernee dvm
fla lic 1820
There were about 70 vets at the EBVM Symposium. You are absolutely right that selling evidence-based medicine is an uphill battle. The latest from the AHVMA is that they are trying to raise $20 million through their foundation to support “integrative medicine” departments in mainstream vet schools. That’s about 2000x the total annual budget for the EBVMA. *sigh*
Of the 70 how many we’re in private practice?
Art
Only a couple in independant private practice. Mostly academia, corporate practice, and industry. Of course, that’s one of the things the organization exists to try and change.
Only a couple in independant private practice. >>>>
do you have any idea how many doctors who write for SBM besides you and david ramey are in private practice? Do you think you were hired because you practice evidence based medicine? When I got out of school and applied for a job in private practice I said I wanted to work for a AAHA practice and got hired in a AAHA practice. the guy that hired me ended up president of AAHA so we were on the same page. If a new grad said they wanted to practice in a private evidence based practice I am not sure that would help them get a job unless the boss was committed to evidence based medicine. Most of the guys I have followed that seem to want to practice EBM end up in public health.
art malernee dvm
skeptvet wrote: “The latest from the AHVMA is that they are trying to raise $20 million through their foundation to support “integrative medicine” departments in mainstream vet schools.”
According to the 2012 winter issue of the IVC Journal, LSU School of Veterinary Medicine has established an integrative medicine program.
http://www1.vetmed.lsu.edu/PDFs/Events/item46774.pdf
Are any other mainstream veterinary schools following suit?
There are individuals interested in alternative therapies at most, if not all, vet schools. Formal programs or curricula tend to get established only when there is a critical mass of believers among faculty and, and this is important, funding. In the human medical field, “quackademic medicine,” that is the infiltration of alternative therapies into mainstream academic medical centers despite the lack of evidence to justify most of these therapies, is ubiquitous. If the AHVMA effort is successful, the same will likely be true in veterinary medicine.