Stumbled across this blog post from VancouverFeline recently. Warms my skeptical heart!!

In medicine, we have many habits and quirks handed down through the generations. Often, we think nothing of these, and even believe that these well-accepted practices are grounded in rational evidence-based thinking. Surprisingly many are not, and even today, medicine is heavily influenced by fashion and eminence.

The word “believe” and all its derivatives has no place in sound medical practice. I cringe every time that word used by specialists in a peer-reviewed journal, article or lecture. If we want medicine to be a religious experience, then there are faith-healers happy to be consulted. Use of the word “believe” implies “I have not thought about this and am accepting faithfully this concept”. Granted no doctor has time to individually explore every medical concept that we use, but a collective level of skepticism is absolutely necessary.

We often think we are being healthily skeptic when, in questioning medicine, we head off in a New Age direction, feeding ourselves and our pets with naturopathic, homeopathic and expensive wonder products. Words that should stop you in your tracks, prompting some deep questions and caution, are “traditional”, “cure”, and “natural”. Just because the ancestors used something, when nothing else was around, and they believed it helped, remember that placebo effect, desperation and faith all come into play (as it does in all medical fields) – before popping something into my body, I would rather see the evidence.

I have been participating in a discussion on the Veterinary Information Network (VIN) about the AVMA’s failure to take a scientific and principled position on homeopathy, and it prompted me to outline a few thoughts on the subject of whether more research on some CAVM therapies is always worthwhile, and what the role of plausibility plays in evaluating such therapies. I’m reposting these thoughts here since these subjects come up often on this blog.

I once thought the answer to separating useful CAVM from nonsense lay in more research. Having spent several years investigating CAVM and the claims and rationales made for it, I realize this is not actually that likely to be helpful, for many reasons. One is that much of CAVM is based on philosophical and ideological foundations completely incompatible with science, and the promotes of these “metaphors” don’t have any interest in applying science to their practices other than its potential value as a marketing tool for creating broader acceptance and legitimacy. (I have written about this before.)
For scientific research to be useful in separating true from false, we must be willing to accept negative results and abandon therapies even if they seem effective in our uncontrolled personal observations. There is rarely any serious will to do so among proponents of CAVM, as illustrated by the homeopathy debate and the comments you and Craig have made about the views of some acupuncture proponents.

It is also the case that the vast majority of the CAVM research done, in human as well as veterinary medicine, is of poor methodological quality and very high risk of bias. It is possible to find many positive studies on almost any practice, yet systematic reviews that base conclusions on well conducted studies with limited bias risk almost always conclude there is no effect beyond placebo. All these poor studies suck up scarce resources and create a misleading impression of the state of the evidence. Again, to help us distinguish true from false, scientific methods have  to be employed in ways that generate reliable evidence that leads to meaningful conclusion which can be applied in practice, and this is seldom the case in CAM research.

So if the research done will not dissuade true believers and is generally unreliable and misleading, how is it going to clarify our understanding or inform our practices? I’m not saying no CAVM should be researched, of course, only that in many cases (such as homeopathy, energy medicine and other forms of vitalism, etc.) the answer is already as clear as it can reasonably ever be, or the fundamental premises of the methods are not amenable to science and rigorous scientific research is not welcomed or heeded by proponents. In these cases, the resources used to conduct such research are wasted and the waters only further muddied.

Which brings me to the second response evoked by your comments. Of course, plausibility is not the definitive standard for judging the efficacy of a therapy. However, the fact that plausible ideas are sometimes false and implausible ones sometimes true doesn’t mean we should jettison plausibility entirely as a tool in evaluating therapies. The pioneering epidemiologist Sir Austin Bradford Hill discussed the multiple interacting criteria for establishing a causal relationship and both the weaknesses and the utility of plausibility in a classic paper I think every clinician should read many times, and which I have also written about before.

Plausibility is a bit like our clinical index of suspicion–it doesn’t give us a definitive diagnosis, but it helps us start moving in the direction most likely to be productive. In the case of veterinary medicine, where resources for research are so scarce, do we really want to spend them on studies of ideas which can only be true if multiple well-established principles of basic science are false? Should we indefinately call for more research on homeopathy and methods for balancing Yin and Yang, or should we put most of our energies and talent towards ideas with a bit higher probability of being true? Plausibility is one of many factors to consider in weighing botht he mertis of a therapy and the value of further research.

Finally, of course all the same principles we are talking about apply equally to conventional therapies. Much of what we do in conventional medicine lacks high-quality supporting evidence, and some of it is even implausible. I challenge the pharmaceutical reps I talk to as vigorously as the herbalists, and I haven’t made any more friends in the world of stem cell therapies or hyperbaric medicine than I have among TCVM practitioners.

However, it is fallacious to suggest, as is sometimes done, that the criticism some of us are making of unconventional medicine are somehow weakened or inappropriate just because conventional medicine is imperfect. Trimming the dross from our repertoire and strengthening the quality of science and care we provide should reasonably start with the least defensible practices. And while I may respect the intelligence and genuine commitment to patient welfare of colleagues who support such therapies, their good perosnal qualities are not really evidence for the therapies they promote any more than the often venal and malicious behavior of some in the pharmaceutical industry is evidence that their products don’t work. As you say, our interventions need to stand on the merits of the evidence concerning them, and opinion is not evidence regardless of the strengths or weaknesses of the source.

The American Holistic Veterinary Medical Association (AHVMA), and the associated foundation (AHVMF) appear frequently in articles on this blog. These organizations represent a large portion of alternative veterinary practitioners, and the AHVMF is involved in significant efforts to spread the gospel of alternative medicine through funding scholarships, faculty positions, and purported research centers focused on alternative therapies. I have writen before about the concern that the efforts funded by the AHVMF are likely to be more marketing than science, focused on promoting therapies rather than on an honest, science-based assessment of their real risks and benefits.

A number of comments made by Dr. Richard Palmquist, the leader of the American Holistic Veterinary Medical Foundation’s very successful fundraising efforts ($900,000 in two years by their report), support this concern. The view of “science” (almost always in “scare quotes” like these) expressed in these comments does not suggest the AHVMF leadership is open-minded about the posisbility that any alternative therapies might be shown to be ineffective (which is unsurprising since, after all, the group vigorously promotes homeopathy). It seems much more likely that this is a group with an unshakeable faith in their beliefs who are simply looking for ways to spread these beliefs using a veneer of scientific legitimacy.

As I’ve said before, I don’t doubt the sicnerity of these folks’ belief in their practcies, nor the superficial honesty of their claims that they want scientific support for these. What I doubt is their ability to set up and generate truly high-quality research and accept evidence inconsistent with their beliefs. It is vital that science not become a mere marketing tool, with lip service paid to research while poor quality marketing studies are produced heavily biased to find the results their funders wish to find. This has been a persistant problem in the pharmaceutical industry, with harmful results for patients, and the same strategy is likley to predominent in the area of alternative therapies, with the same results, if high scientific standards are not adhered to.

“Scientific advance can be fueled by a few people who have experienced the impossible and who care enough to investigate and share.”

“When we use “science” to kill hope by stopping progress we find real harm occurring.”

“Love and Truth are brick and mortar in the path from impossible and implausible to possible.”

“Funny that science advances from “impossible” to “it happens,” to “here’s how we do it.””

“Comfortable science involves reading & discussing well established data. Uncomfortable science occurs in the interface inhabited by pioneers”

“”Study” means “to look.” Deniers of Truth often refuse to look as a strategy to protect their ignorance or false authority.”

“If someone criticizes you for seeking love and truth, smile and continue because success is approaching sooner than you might think. :-)”

“Truth once raised is often greeted by antagonism, debate and attack, but being Truth it can and does persist. Dialogue & love gives breath.”

“A miraculous response on one patient can not prove cause, but similar results open the door to research and understanding. We want to know! Creating dialogue between clinicians and academic researchers allows for information to move more quickly. Report ur miracles.”

” thanks for believing in miracles.”

“When a miracle surpasses our science, we can deny the miracle or use our science to pursue improved understanding. It’s a choice.”

“The road to miracle can be short or painfully arduous as we expand our possibilities always seeking truth and a better way. Keep walking…”

“Miracles provide us the opportunity to see and share the unexpected as we gain insight into new relationships. RT if u believe in miracles.”

“Placebo effect (that means YOU) are responsible for HALF of a drug’s effect. How about making more of YOU!?”

“90.1 percent of AVMA delegates voted against the anti homeopathy resolution. Veterinarians free to pursue whatever tools needed to help.”

“In the end we do not heal from finding out what is wrong. We heal when we find and connect what is right with our lives.”

“We will have health reform when doctors become team members celebrating and developing potential and not simply pill prescribers.”

“Thousands of scientific paper exist for homeopathic agents. Science is developing much more rapidly now. If we look we discover truth.”

“People who are sure they know how the universe works are often in for a surprise. “Scientists” often fight what turns out to be right.”

I suppose I must be a Denier of Truth using science to kill hope? Hmmm….

The Journal of the American Medical Association and British Medical Journal have produced a video of a discussion with some of the founding figures of the Evidence-Based Medicine movement. This offers some great insights into the improtant and fundamental shift in how clinical practices are evaluated in human medicine, and why such a shift needs to happen in veterinary medicine as well. I encourage everyone to have a look!

A key focus of this blog is to promote a science-based perspective for veterinary medicine. I believe that relying more on science and less on habit, tradition, intuition, and personal experience will lead to better care for our patients. While almost everyone claims to support science when asked, it is clear from the topics I report on that many in the veterinary profession, particularly those practicing alternative medicine, don’t really mean it, or at least don’t understand what science-based medicine really means. It is simply impossible to believe in the scientific approach and still practice homeopathy without the most egregious kind of doublethink.

The best hope for improving veterinary medicine and moving further towards science and further away from mysticism and pseudoscience is to teach veterinary students how to think and reason critically, how to evaluate the quality and meaning of different kinds of evidence, and how to recognize and watch out for the errors and biases in their own observation and reasoning; in other words, to teach the epistemology of science and evidence-based medicine.

The alternative, of course, is to teach continuing reliance on blind acceptance of the dogma of one’s teachers and uncritical faith in one’s own observations and the anecdotes of others; in other words, to teach the epistemology of alternative medicine. I have written about the philosophical differences between science and alternative medicine before, and the two often have very different, and incompatible, ways of establishing and verifying knowledge.

Unfortunately, what veterinary students are taught is not determined by any objective standard of reasoning about science and the nature of how knowledge is obtained and evaluated, but by what the teachers believe about the content and processes of veterinary research and practice. And teachers, like all other human beings, have their own biases and interests. There are also complex politics in academia, as in any other human endeavor. And, of course, few of the teachers in veterinary medicine today have themselves been trained in modern evidence-based medicine, which has only become the dominant approach in the human medical profession over the last two or three decades. The practice of passing along the “wisdom of the ages” to the next generation of doctors is far older and more entrenched, however less reliable an approach it may be.

So despite the fact that alternative therapies are currently a relatively marginal part of veterinary medicine, they appear to be growing some in popularity and respectability, and this raises the danger that the next generation of veterinarians will be trained with the idea that even egregious quackery like homeopathy and energy healing are potentially useful practices to be taken seriously. What, then, are the veterinary students of today being taught? How prominent are courses in evidence-based medicine and in alternative medicine?

A thorough answer would require a detailed review of the curricula of all the veterinary schools in the U.S., or any other area one was interested in. I certainly do not have the resources to conduct such a study. However, there is some information available which suggests the relative emphasis on the fields of evidence-based veterinary medicine (EBVM) and complementary and alternative veterinary medicine (CAVM).

The Teaching of EBVM
The Evidence-Based Veterinary Medicine Association (EBVMA) has informally surveyed the veterinary schools in the U.S. and identified which have courses in EBVM and which teach at least some of the methods or concepts of EBVM in other courses.  This information is available on the EBVMA web site.

As far as could be determined, of the 35 schools looked at, only one has a  course specifically in EBVM, and one other has a course that covers the basics of EBVM along with other material aimed at raising the standard of practice. Beyond that, most schools (26) include some EBVM material in other courses, such as those in public health, epidemiology, and statistics. This suggests that most veterinary students get some exposure to EBVM, but rarely is it presented comprehensively or as an essential strategy for high quality clinical practice.

This is consistent with the findings of a pilot survey, also conducted by the EBVMA in 2011, which suggested most private practitioners have heard some EBVM terms but have little understanding of them and feel unprepared to find and appraise research studies. In this survey, 85% of respondents reported no formal training in literature search and appraisal, and between 30% and 85% were not sufficiently familiar with key EBVM concepts to explain them to others.

It is also consistent with the results of a study carried out in Belgium, in which the decision-making practices of veterinarians were investigated. In that study, “The EBM approach was never mentioned in any of the interviews, with occasional isolated opinions such as ‘The information from research is not important and does not influence decisions.’”

For practicing veterinarians, there is little opportunity to remedy this deficiency in education once they leave school, as there are few courses in EBVM available privately. Some EBVM material is covered in continuing education meetings, and there is a project beginning at one veterinary school to develop EBVM curricula for vets in practice, but the options are limited.

The Teaching of CAVM
A survey of CAVM courses at veterinary schools was conducted in 2011, and it found a somewhat different picture for this collection of therapies.

Sixteen schools indicated that they offered a CAVM course. Nutritional therapy, acupuncture, and rehabilitation or physical therapy were topics most commonly included in the curriculum. One school required a course in CAVM; all other courses were elective… Eighteen veterinary medical schools had no course offerings in CAVM…

4 [schools] had positions (< 0.5 full-time equivalent faculty) devoted to teaching CAVM…

This suggests that CAVM is being taught pretty widely in veterinary schools; perhaps more widely than EBVM. However, CAVM is a heterogenous category notoriously difficult to define. It is common for CAVM proponents to label perfectly ordinary conventional subjects, such as nutrition, as alternative. The inclusion of nutrition in this survey raises questions about whether the therapies being taught were truly alternative (such as raw diets, TCM-guided nutrition, etc.), or simply an appropriation of science-based nutritional recommendations to the standard of “alternative” therapies.

Similarly, physical therapy and rehabilitation are, in human medicine, perfectly ordinary conventional medicine. Due to the limited research in this area in companion animal medicine, this filed is a bit of a gray area at the moment, with reasonable extrapolations from human medicine employed side-by-side with alternative therapies like Veterinary Orthopedic Manipulation, chiropractic, and acupuncture.

This figure illustrates the sort of CAVM modalities being taught, and it certainly includes both outright quackery, such as homeopathy, and more ambiguous practices.

Figure 1—Coverage of topics in a CAVM course (dark gray bars) or in other courses in the curriculum (light gray bars) at 16 COE-accredited veterinary medical schools that offered a course in CAVM. PT = Physical therapy. TCM = Traditional Chinese medicine.

The survey also suggested that CAVM was more widely taught in 2011 than it had been in a previous survey.

Coverage of CAVM appears to have increased substantially since a previous survey3 of CAVM coverage in veterinary medical curricula. In that survey,3 7 of 23 veterinary medical schools offered courses in CAVM, compared with 16 of 34 schools that offered courses in CAVM in the present survey

It would not surprise me if there has been some growth in the teaching of CAVM as my impression is that there is some growth in the popularity of these therapies in veterinary medicine, though that is difficult to determine objectively. However, the key point regarding the teaching of these methods is made by the authors in this statement:

…the extent of CAVM coverage appears to be driven largely by individual faculty members who happen to have an interest in 1 or more areas of CAVM.

There is no tsunami of new evidence to support greater integration of CAVM in the veterinary curriculum; there are simply individual faculty members interested in such methods. This illustrates the potentially significant impact individual faculty members can have on the profession.

The other key point identified was that the leadership of the veterinary schools appear to have some concerns about the evidentiary integrity of CAVM:

The most frequently and strongly expressed comment in the survey reported here was that any coverage of CAVM in the curriculum, whether in a separate course or as part of other courses, must be via evidence based medicine.

This sounds encouraging, and it indicates that the folks surveyed realize CAVM has a shaky evidence base. However it is unfortunately too easy for proponents of even egregious nonsense like homeopathy to generate the appearance of scientific evidence or rigor. Simple li-service to EBVM or the generation of numerous low-quality studies doesn’t prevent the integration of pseudoscience with CAVM therapies that have real potential benefits.

I have no doubt that the leadership of most veterinary colleges are sincere in their desire that their students be taught truly science-based medicine, I know that the American Holistic Veterinary Medical Association (AHVMA) and other pro-CAVM groups are eager to use research, and funding for research, as a pre-text for promoting therapies that are truly incompatible with legitimate science. The charitable foundation of the AHVMA has made the following statement:

One of our goals is to generate five to seven academic and research teaching hospitals in the United States of America that are qualified, able and willing to do appropriate evidence-based veterinary research into these techniques and philosophies…our ten day campaign that netted over $480,000 in contributions dedicated to this purpose.. Our goal is to generate a twenty million dollar fund to support these centers.

Does anyone believe these individuals or groups will find any CAVM practices to be without merit? Is there any research that can convince the leadership of the Academy of Veterinary Homeopathy that homeopathy is without value? I am not highly confident that the substitution of marketing for real science will be readily seen for what it truly is.

It must also be noted that, in contrast to the situation with EBVM, there are numerous for-profit organizations willing to train and “accredit” veterinarians in the practice of specific CAVM practices. The marketability of alternative therapies is inherently greater than that of the EBVM method, and this makes the financial resources available for promoting and teaching CAVM, and the incentives for doing so, correspondingly greater.

Bottom Line
There is some teaching of the principles and methods of EBVM in veterinary schools, but it is less consistent and integral to the curriculum than it should be, and it is not likely to produce veterinarians committed to EBVM and capable of practicing according to EBVM standards. In contrast, there are much more aggressive and well-financed efforts under way to promote training veterinary students in CAVM methods, both those with some plausibility and reasonable supporting scientific evidence and those that are clearly nonsense. It seems likely that this situation will lead to the greater appearance of legitimacy to CAVM in general, regardless of the actual development of compelling scientific evidence favoring CAVM practices. Students taught CAVM will become vets who practice or refer for CAVM simply because it was presented to them as appropriate in school. Students not taught EBVM will not likely investigate and critically evaluate the evidence base for these practices for themselves but will take the word of their teachers for the value of such therapies. This has the potential to lead to more widespread use of ineffective therapies and less critical thinking among veterinarians, which will not improve the care veterinary patients receive.

It is incumbent, then, upon anyone committed to a sound scientific basis for veterinary medicine that we encourage the teaching of EBVM principles and methods and insist upon the application of these uniformly, to both conventional and alternative practices. No special exemption from scientific standards of evidence should be granted to alternative therapies simply because they have a history of use or dedicated adherents. Truly fair, unbiased, and scientific evaluation of all therapies can only take place if the epistemology of science is accepted as superior to the fuzzy epistemology of history, tradition, and personal experience, and if EBVM methods are consistently, rigorously, and uniformly applied. And this will only happen in the future if veterinary students are trained to think the way now.