Alternative Standards for Alternative Continuing Education Courses

I have written several times about the efforts of alternative vets to circumvent the systems intended to ensure quality and scientific legitimacy in continuing education for veterinarians. In brief, most states require vets to regularly take a certain number of hours of continuing education. The idea is that scientific and medical knowledge grows and changes over time. Since states give vets an exclusive monopoly on practicing veterinary medicine, they want to ensure the public is protected against veterinarians who have outdated or inaccurate knowledge and skills.

Such requirements are meaningless if there is no control over the kinds of education vets can use for this license requirement. If I can take a class in origami or a Renaissance poetry, that’s great fun but it doesn’t help ensure I am an up-to-date and competent vet. So most states require continuing education (or CE) courses be accredited to be used for licensure. Vets can still take any courses they want in any subject, they just can’t get credit for them for licensing purposes unless they are accredited.

The American Association of Veterinary State Boards (AAVSB) is the main organization recognized as accrediting CE courses, through its RACE group. Appropriately, RACE requires the content of CE courses have some minimal scientific evidence or compatibility with science.

[Courses must] build upon or refresh the participant in the standards for practice and the foundational, evidence-based material presented in accredited colleges or schools of veterinary medicine or accredited veterinary technician programs…CE programs that advocate unscientific modalities of diagnosis or therapy are not eligible for RACE approval…All scientific information referred to, reported or used in RACE Program Applications in support or justification of an animal-care recommendation must conform to the medically accepted and scientifically supported standards of experimental design, data collection and analysis.

This category includes all conventional medical and surgical sub-categories that are evidence based… Based on scientific principles, there must be an established “probability” of success that conforms to the medically accepted and scientifically supported standards of experimental design, data collection and analysis.

1. Content of a Category One: Scientific Program must be supported by:
2. Availability of beneficial evidence (peer reviewed journal) OR
3. Three peer reviewed studies OR

iii. Study review – Case control studies leading to the benefit of the patient OR

1. Evidence based studies OR
2. Proven usefulness /effectiveness OR
3. Evidence of rigorous scientific research OR

vii. FDA (animal approved) objective information/about the product (safety) plus one of the categories above.

RACE does approve some CE offerings involving alternative therapies, but many do not qualify for accreditation due to lack of compliance with RACE requirements for scientific validity. Organizations of alternative medicine providers have often responded to the denial of RACE approval not by producing better scientific support for the disputed content but by circumventing the approval process. The American Holistic Veterinary Medical Association (AHV MA) and other groups have advocated bypassing RACE and getting CE approval directly through the states. Smaller numbers of individuals are better able to influence the political process at the state level, so this has often been a successful strategy.

Also, since the AHVMA has now qualified for a seat in the AVMA House of Delegates, some states automatically accept their content as legitimate CE regardless of scientific validity or RACE approval. House of Delegate membership essentially only requires only a certain number of members who also belong to the AVMA, so it is not a mark of any kind of legitimacy to the mission of the organization. However, it is a useful component to an overall campaign to market alternative medicine, and in this case it facilitates bypassing the usual standards veterinary CE courses must meet.

The Academy of Veterinary Homeopathy (AVH) actually sued AAVSB over denial of RACE approval, unsuccessfully. (1,2)

But the CAVM community has gone even further, creating an alternative CE accreditation board specifically to approve alternative medicine content, RAIVE. As they state on their web site:

The CAVM community now relies on RAIVE to validate their educational meetings. We urge all state boards to do the same for CAVM courses. The opinion of the RACE committee is no longer valid.

Failing to approve every element of their CE offerings, regardless of scientific validity, apparently invalidates the entire CE approval process. The AHVM, RAIVE and other CAVM organizations are now attempting to get state veterinary medical boards to accept RAIVE accreditation as comparable to RACE approval. Washington state, for example, is currently accepting input on a proposal to do just this (The proposal)

The RAIVE web site argues there is no need to demonstrate scientific validity for CE offerings, only that CAVM should be taught by “experts” in that field. As I have pointed out before, that by definition requires that any judgment of CAVM be made by individuals who already believe in its safety and efficacy and have committed themselves to practicing and teaching specific modalities. This effectively eliminates any possibility for falsifying or even significantly challenging these methods, and makes the standard of validity not scientific evidence but expert opinion. It is the perfect closed shop.

The site further specifically states that scientific evidence is a secondary consideration and need only be developed if the methods they advocate are already accepted and taught:

RAIVE recognizes that evidence based medicine does not define the practice of veterinary medicine, but is a process of clinical decision-making, and veterinarians can also benefit from education in emerging subjects with little scientific support. In these cases, RAIVE approved CE must incorporate experts with advanced training or deep clinical experience in these subjects.

RAIVE recognizes that not all CAVM modalities meet the currently accepted standards of evidence. However, RAIVE also recognizes that in order for the evidence to be produced, CE in these modalities must be encouraged in order to develop and strengthen skills in practitioners of these modalities.

So we should teach people to use these methods first, and then maybe test them scientifically later? This effort to avoid the usual standards of evidence that conventional veterinary CE offerings are expected to meet, and to specifically reject scientific testing as the primary standard in favor of individual expertise, reflects the common view often manifest in the CAVM community that science is useful only for proving what one already “knows” from personal experience or for convincing others of the validity of such knowledge. The issue is not whether CAVM methods are or can be scientifically validated. Some practices might meet this standards, and others clearly do not. As I’ve said repeatedly, many aspects of CAVM can and should be investigated scientifically. But others, like Chinese Medicine and Reiki, cannot be because they are belief systems not scientific hypotheses. Others, like homeopathy, have already been evaluated and proven not to work. And CAVM proponents themselves often claim scientific evaluation is unnecessary or inappropriate for their methods. Is it really appropriate for a vet to maintain their license, their legal monopoly to practice veterinary medicine, by study things that are inherently unfalsifiable or incompatible with science or that have already been proven false?

The core issue is that the ethos of the CAVM community views scientific evidence as, at most, a nice extra to add on after one has already figured things out by trial and error and, at worst, completely irrelevant to the evaluation of the treatments we use on our patients. This is not just a disagreement about the evidence for specific practices, but an attempt to fundamentally alter the epistemological foundations of veterinary medicine.

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