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!