For a while now, the Huffington Post has been providing a platform for a prominent voice in the alternative veterinary medicine community, Dr. Richard Palmquist. Dr. Palmquist is involved in the American Holistic Veterinary Medical Association (AHVMA), and has had some rather unkind things to say about CAM skeptics in general, and about my criticisms of the AHVMA in particular. It is unfortunate that someone whose ideas are so far outside the mainstream has been given such a prominent pulpit for disseminating misinformation, and that pet owners are unlikely to realize that Dr. Palmquist’s theories do not accurately represent the science of veterinary medicine or the opinions of most veterinarians.

He must be given credit, however, for representing his position skillfully. One element to putting a positive PR spin on unproven or disproven remedies is the technique known as bait-and-switch (though it is more commonly referred to as “integrative medicine”). This involves recommending or using widely accepted conventional therapies based on scientific reasoning and evidence, and then tagging on unproven therapies or pure nonsense treatments as if they were in the same category. In his most recent post, Dr. Palmquist discusses allergies, which in dogs and cats usually manifest as itching and infections of the skin in response to allergens from fleas, food, or environmental sources (such as dust mites, pollens, etc). There is a good deal of sound scientific research on allergies in pets, and the veterinary dermatology community regularly provides summaries of the research in statements on Evidence-Based Allergy Treatment.

Much of Dr. Palmquist’s post is perfectly consistent with a scientific understanding of the cause and treatment of allergies. He discusses antihistamines, corticosteroids, immunotherapy (aka allergy shots), limited antigen diets, and fish oil supplements, all of which are therapies supported by reasonable plausibility and research evidence. In this discussion, of course, he continuously minimizes the benefits and expounds at length on the potential risks, a clear effort to bias the reader against these therapies while ostensibly acknowledging that they have proven efficacy.

In particular, he harps on the notion that antihistamines and steroids “turn off” parts of the immune system. This sounds like a terrible thing, because everyone knows the immune system is necessary to protect us from infectious disease. So are we compromising the defenses of our patients with these drugs? If properly and judiciously used, no. The implication ignores the complexity of immune function and the effects of anti-inflammatory medications, probably deliberately in order to increase the negative associations people may have in their minds with these medicines.

In response to stimuli, such as infectious agents or allergens, cells in the immune system release chemicals, called cytokines, which lead to the classic inflammatory response: redness, swelling, itching or pain, and sometimes systemic effects such as fever or lethargy. Inflammation is not inherently a good thing. In fact, it can be quite harmful. While a mild fever may help fight off an infection, a high fever that causes brain damage is clearly doing more harm than good. And while activation of the immune system in an effort to fight off disease-causing organisms is a good thing, allergies are by definition an inappropriate activation of the system against proteins that are not inherently harmful. They are uncomfortable chronic diseases caused by excessive, unnecessary activity of the immune system. Even worse are auto-immune diseases, like lupus, hemolytic anemia, and so on, are serious, even deadly consequences of inappropriate immune-system activity. So the implication that turning off part of the immune system is a dangerous or unnecessary part of treating diseases that manifest as excessive immune system activity is nonsense. Suppressing excessive inflammation is exactly what is needed to treat the discomfort or even serious harm these diseases can cause.

It is possible, of course, to increase a patient’s susceptibility to disease with excessive or prolonged use of anti-inflammatories, and undoubtedly some doctors do not use these drugs judiciously. But anything in medicine that has a benefit has a potential risk, and it is disingenuous of Dr. Palmquist to focus primarily on the risks of conventional therapies and the unproven but assumed benefits of alternative methods regardless of the state of the evidence.

Of course, the agenda behind this damning with faint praise of conventional treatments is to build a case for the alternative treatments with which he concludes his article. He first includes limited antigen diets in his list of alternative treatments, though it is a widely accepted conventional therapy, probably because of the mistaken notion that any treatment that is not a drug must be a form of alternative medicine. He also includes fish oils, which are another treatment widely used in conventional medicine, though with only limited supportive evidence.

His descriptions of herbs and supplements, homeopathy and homotoxicology, and other such alternative therapies fairly glow with praise: “can be amazing,” “allergic responses can vanish entirely,” etc. And with the sole exception of high-dose Vitamin C supplementation, no potential risks or unwanted effects are mentioned for any of these treatments.

Dr. Palmquist does state that, “The scientific evidence varies for these methods,” and he supports this statement by reference to the summary of evidence-based allergy treatment I referred to above. However, with the exception of diets and fish oils (neither truly alternative) and phytopica (which Dr. Palmquist doesn’t mention), this review does not provide any evidence in favor of alternative therapies, and in fact it mentions almost none of those he recommends. There is no legitimate scientific evidence to support the utility of acupuncture, Traditional Chinese Medicine theory, homeopathy, homotoxicology, glandular extracts, or digestive enzyme supplementation in the treatment of pet allergies. And most of the herbs and supplements he recommends have little to no evidence to support veterinary allergy use. And yet he discusses these therapies as if they were as effective, and certainly safer, than the proven conventional therapies he so lukewarmly discussed at the beginning of the article.

No question this is a slick bit of propaganda designed to cast doubt on the safety of conventional therapies and to guide readers towards unproven or outright useless alternatives that are presented as if they were legitimate, accepted therapies of proven safety and efficacy. There is an impressive list of supporting references, though many of them are either books written by other proponents of alternative therapies, or articles which, like the dermatology task force review, don’t actually support the safety and efficacy of the alternative therapies being promoted. Some are legitimate studies investigating the safety or efficacy of conventional treatments, but the purpose is clearly not to review the available treatments fairly but to build a public relations case for alternative and against conventional science-based allergy treatments. Though I’m sure Dr. Palmquist feels this is for the greater good, since he is a true believer in the therapies he promotes, in reality such misinformation presented as if it were established fact and biased towards the unproven is not truly in the best interests of our patients or clients.

From the Science-Based Medicine Blog: Complementary and Alternative Medicine in Hospice Care

A number of news outlets (e.g. Bloomberg Business Week, MSN.Com, US News, etc) have recently reported that use of complementary and alternative therapies (CAT) is widespread in hospice care facilities. This is based on a report from the Centers for Disease Control, Complementary and Alternative Therapies in Hospice: The National Home and Hospice Care Survey, Untied States, 2007. According to most news reports, about 42% of hospice care providers offer some kind of CAT.

I was initially inclined to find this a little worrisome. In my own field of veterinary medicine, advocates of alternative therapies are prominent among the organizers of the nascent hospice care movement. And while I am strongly supportive of better and more available veterinary hospice care, the involvement of CAM advocates raises the concern that animals at the end of their life might receive ineffective palliative care, or be denied the benefits of conventional treatments by some CAM providers, who often characterize “allopathic” treatments as “unnatural” and harmful.

In practice, I have seen this happen to patients with terminal diseases. I will never forget a Rottweiler dog I diagnosed with osteosarcoma, a very painful bone cancer, whose owner was convinced that homeopathy was adequate to control his pain and refused to use NSAIDs because of her conviction they were “toxic.” I have also seen my patients denied euthanasia even in the face of great suffering because so-called “animal communicators” claimed the pet was “not ready to leave” and had expressed a desire to remain with their owner as long as possible.

Perhaps these experiences have made me overly sensitive on this subject, but I saw these recent news reports and pictured people at the end of their lives being similarly denied effective palliative care or subjected to pointless therapies like homeopathy and “energy medicine,” or even more worrisome treatments like chiropractic or herbal remedies with real risks. However, a little digging into the details suggests that the headlines are a bit misleading, and these fears are probably unfounded.

As always, when trying to assess how popular alternative medical therapies are, the tricky issue arises of defining “alternative.” In this study, the authors referenced the MedlinePlus definition:

Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard care. Standard care is what medical doctors, doctors of osteopathy and allied health professionals, such as registered nurses and physical therapists, practice. Alternative medicine means treatments that you use instead of standard ones. Complementary medicine means nonstandard treatments that you use along with standard ones. Examples of CAM therapies are acupuncture, chiropractic and herbal medicines.

Personally, I prefer Dr. Novella’s definition:

CAM is a political/ideological entity, not a scientific one. It is an artificial category created for the purpose of promoting a diverse set of dubious, untested, or fraudulent health practices. It is an excellent example of the (successful) use of language as a propaganda tool.

In any case, in order to measure the popularity of something, one has to define it in some way, and in the past assessments of how popular or widespread CAM use is have created misleading impressions due to dodgy definitions. For example, the 2007 National Health Interview Survey (discussed in detail here) reported 30% of Americans to be regular CAM users. A closer look at the details of the survey, however, showed that very little of this self-reported usage involved the application of the usual dubious CAM approaches (e.g. acupuncture, chiropractic, homeopathy, various herbal traditions, etc) to treat specific medical problems. Much of this supposed CAM usage involved the non-medical application of massage, yoga, tai chi, prayer, and so on to provide psychological comfort or facilitate relaxation.

Of course, if one argues that massage, yoga, or even prayer are effective in reducing the objective signs or disease, or even bringing about a cure, then one could argue these are forms of alternative medicine. But such methods are mostly employed to provide comfort and help patients cope with their illness, and as such they can be valuable and legitimate interventions. This does not make them medical therapies, however, alternative or otherwise.

The hospice care survey suffers from the same kind of problematic definition for “complementary and alternative.” According to the report’s technical notes, providers of hospice care were asked first to choose all the services they offered from a list, and “Complementary and Alternative Medicine (CAM)” was one of the choices. Those that indicated they offered CAM were then asked to indicate “Which of these complementary and alternative medicine therapies does this agency use?”

Here is the list:

1. Acupuncture
2. Aromatherapy
3. Art therapy
4. Guided imagery or relaxation
5. Massage
6. Music therapy
7. Pet therapy
8. Supportive group therapy
9. Therapeutic touch (a westernized version of reiki)
10. TENS (Transcutaneous Electrical Nerve Stimulation)
11. Other

Personally, I see little on this list that I would classify as CAM. Acupuncture, certainly, along with therapeutic touch (like reiki) and aromatherapy. But most of the rest, unless specifically marketed as treatments for disease, seem more like benign, pleasurable activities designed to provide comfort, relaxation, and enjoyable stimulation. As a veterinarian, I work with a lot of pet therapy dogs, and I have yet to run across a handler of one who thought they were practicing alternative medicine! (Though I suppose there might be some such folks out there). And TENS is a perfectly conventional intervention, often somewhat disingenuously confused with acupuncture.

The most popular of the “true” CAM therapies offered was therapeutic touch, available at 48.3% of facilities. Aromatherapy was offered by 39.7% of hospice providers. I cannot even find a number for acupuncture in the report. And by far the most popular “alternative” therapies offered were massage (71.7%), group therapy (69%), music therapy (62.2%), and pet therapy (58.6%).

The report also indicates that only 8.6% of patients discharged from a hospice facility that offered CATs actually received one of these therapies. So even under such a loose definition of alternative, there is no evidence that large numbers of hospice patients are receiving alternative medical treatments.

It wouldn’t surprise me if we begin to see advocates of alternative medicine proclaiming that this report shows CAM is widely available, popular, and even indispensible in hospice care. The 2007 National Health Interview Survey results were frequently used this way to create the impression that CAM is becoming mainstream and that resistance to it is the province of extremists and ultimately futile. The details of both surveys, however, indicate that even with aggressive expansion of the definition of CAM to include conventional therapies such as TENS and non-medical interventions like pet therapy, CAM is not truly as popular ubiquitous as its proponents claim.

There is little objectionable from a science-based medicine perspective in most of the therapies hospice care providers are offering, according to this study. I enjoy a good massage, relaxing music, and the company of a friendly dog as much as anyone. And those elements that are truly nonsense, such as therapeutic touch and aromatherapy, are unlikely to do harm or replace appropriate conventional therapies, and they seem in any case not to be especially popular with patients even when they are available. So regardless of what PR use is made of this study, it does not suggest that human hospice care is becoming predominantly the domain of CAM providers, as I might have feared. I only hope the same will be true of veterinary hospice care as that becomes, hopefully, more commonplace.

A recent study in the journal Animal Cognition involving drug and explosive detection dogs has been widely reported in the online media (e.g. Medical News Daily, Sacramento Today, etc). The study, conducted at the University of California at Davis, was cleverly designed to explore the unconscious influence of detection dog handlers on their canine partners. It provides an excellent example of how greatly the beliefs and expectations of humans can unintentionally affect the behavior of dogs, even when both the human and the dog are highly trained professionals. The study is interesting in its own right, but it is also relevant to veterinary medical research since the problem of the unintended effects of human beliefs and expectations creates significant challenges for assessing the efficacy of veterinary medical therapies.

In this study, 18 detection teams were tested in each of 4 different rooms, none of which contained any explosives or drugs as a target. Therefore, any positive alert response from the dogs was an incorrect (or false positive) response. Handlers were told that a red piece of paper would be present in some rooms and would indicate the location of a substance the dog should detect. In reality, this piece of paper was a decoy intended only to create and expectation in the mind of the handlers that their dogs should exhibit a positive response. The 4 rooms contained the following:

1. No target, no paper decoy for the handler, no scent decoy for the dog

2. No target, a paper decoy for the handler, no scent decoy for the dog

3. No target, no paper decoy for the handler, a scent decoy for the dog (sausages and tennis balls)

4. No target, a paper decoy for the handler at the same location as a scent decoy for the dog (sausages and tennis balls)

Each of the teams was tested in each room, and there were a total of 225 incorrect responses (in which the dog sat/lay down and/or vocalized as it had been trained to do to indicate it had detected a target substance). There were false responses in all rooms, but interestingly there were more mistakes in the rooms with only a paper decoy for the handler than in those with a scent decoy for the dog. This would seem to suggest that the unconscious behavioral cues given by the handler affected the dogs’ performance even more than the presence of food or toys!

It is easy to see the implications of this finding for veterinary medicine. Many of the symptoms we look at in evaluating the effect of treating a patient, and many of the variables we measure in research studies of medical treatments, rely on owners or veterinarians observing the behavior of our animal patients. Most attempts to assess pain, itching, activity level, nausea, appetite, behavior and many other key indicators of health are ultimately dependant on subjective interpretation by owners and veterinarians.

We already know that our own expectations and biases can influence what we see and how we interpret it. That is, after all, the major basis for the placebo effect, and why it disappears when we don’t know if the patient is getting a real treatment or a placebo.

But what this study suggests is that the patients’ behavior is likely also affected by our expectations and biases. This is yet another element to the placebo-by-proxy effect, in which ineffective therapies are believed to be working because of non-specific treatment effects (aka placebo) on the owners or the doctors evaluating the treated patients. One of the best examples of this is the use of glucosamine for arthritis in pets, which the balance of the evidence pretty clearly shows doesn’t work but which many veterinarians and owners cling to tenaciously as a useful therapy regardless.

A study like this one shows quite clearly how our expectations and beliefs strongly effect the behavior of our dogs. And this was a study of experienced professional handlers who undoubtedly had been trained in how to avoid misleading their canine partners. Those of us without such training or unaware of the risks of such unconscious influences are likely at even greater risk for unintentionally changing our pets’ behavior in ways that conform to our beliefs. Could our dogs play more, scratch less, eat better, seem happier, or otherwise appear to benefit from treatments we give them partly because we want them to and we expect they will? This study suggests the answer is “Yes!” and reinforces the importance of properly controlled research in evaluating medical therapies.

There is a brief commentary (subscription required) in the current issue of the Journal of the American Veterinary Medical Association (JAVMA) on the subject of veterinary hospice care. I’ve written about this subject before, and I think it is one that deserves more attention and effort in the veterinary medical community.

Thanks in large part to the successful advances in preventative healthcare and treatment of disease, our pets are living longer. The natural consequence of this is that we are more frequently faced with the challenges of complex geriatric medicine and with individuals at the end of their lives who have multiple, often chronic diseases. These disease are generally not curable, but they can often be managed to provide a good quality of life for our patients. When we are able to accept the inevitability of death, which is difficult in our culture, then we can focus on trying to maintain a comfortable, satisfying life for our pets even as they are approaching the end of their lives. This is a worthy goal which presents a number of scientific, psychological, and logistical challenges.

The concern I expressed when I first wrote on this subject, about the role of CAM and associated ideologies in hospice care, is alluded to in the JAVMA commentary.

Hospice care may be more popular among those interested in alternative and complementary therapies. Thus, veterinarians engaged in hospice care should be comfortable working alongside individuals offering these therapies and be aware of the potential for conflicts and deleterious interactions between these therapies and conventional medical treatments.

Though I am not aware of any objective research data to support it, I tend to agree with the contention that pet owners interested in comprehensive hospice care, and often reluctant to consider euthanasia when their veterinarian suggests it is appropriate, are also owners more inclined towards CAM therapies. Much of CAM is vitalistic philosophically, emphasizing the “spirit” or “life force”  of the individual as the primary focus of health and disease, with the physical body considered secondary. And from such a perspective, death is likely to be seen primarily as a transition of the spirit from one state to another, with the dysfunction and breakdown of the physical body as a secondary concern.

This blog, and certainly the veterinary consultation room, are not appropriate places to debate religion or metaphysical philosophy. I don’t see it as at all my role as a veterinarian to challenge my clients’ attitudes about the fundamental nature of life and death. However, I do see my role not only as a source of support and comfort for the client but as an advocate for the welfare of my patient.

Pet owners clearly want the best for their pets, but they also are influenced by their own feelings and needs, especially at intensely emotional times like the end of life. Under such conditions, it is not difficult to project one’s own needs and beliefs onto an animal companion, especially with the facilitation of “animal communicators” or others who claim to have mystical insight into the wishes or thoughts of animals. This can lead to decisions about care which are not truly in the best interests of the pet.

Insofar as CAM is sometimes more successful at meeting people’s psychological and spiritual needs than science-based medicine, and that it is most often employed in the treatment of chronic diseases for which there is no definitively effective conventional treatment, I am not surprised that CAM and CAM providers are playing a significant role in the nascent veterinary hospice movement. CAM providers are among the most active promoters of hospice care.

While I applaud these efforts, I am concerned that ineffective, pseudoscientific therapies may come to dominate end-of-life veterinary care, and that the consequence of this may be inadequate palliation of  our pets’ physical suffering. I have had clients who were struggling to accept the inevitable loss of an animal companion and who sought any and all therapies that offered the promise of a benefit. Even when these therapies were clearly ineffective, or caused increased suffering, these clients have difficulty seeing and accepting this fact at the time (though they often come to me later and lament having persisted too long in the face of their pet’s suffering because letting go was too painful). There are plenty of examples in human medicine of ineffective alternative therapies that actually worsened the quality of life for terminally ill patients using them, and I believe this is a real risk for veterinary hospice care.

I have also seen clients whose pets were in great pain but who refused conventional pain therapy and persisted in the belief that homeopathy and other alternative therapies were effectively managing their pet’s discomfort despite clear and obvious evidence to the contrary. Again, this is not due to any lack of intelligence or compassion, but simply to the innate tendency of all human beings to see what they want and expect to see. Unfortunately, without legitimate scientific research it is not possible to know how effective a medical therapy really is, and I am concerned about patients in veterinary hospice care being denied effective palliative care in favor of bogus therapies because of a philosophical predisposition of some pet owners and hospice providers towards  CAM approaches.

I would certainly not suggest that veterinarians who wish to provide comprehensive hospice care automatically refuse to work with CAM providers or accommodate their clients’ interest in such therapies. This would likely be counterproductive as it would drive these clients away from conventional care or lead them not to disclose the CAM therapies they are using, making it harder to monitor for possible adverse interactions.

However, I do think veterinarians have an ethical responsibility to advocate for the welfare of their patients, even if this means telling clients things they don’t want to hear. If an owner is unable to see or accept that their pet is suffering, or mistakenly believes they are providing effective care, their veterinarian must try, as kindly but clearly as possible, to help them see the true situation. And in extreme cases, where a CAM provider is actively discouraging an owner from taking advantage of appropriate conventional care, it may not be possible to serve that owner and one’s conscience at the same time.

And while there are some people who have a philosophical or religious objection to euthanasia, I think most veterinarians and pet owners see it properly as an act of kindness to relieve otherwise untreatable suffering. If a client is unwilling to consider euthanasia, then their veterinarian may have to accept this and do whatever they can to ensure that the pet is kept as comfortable as possible while dying. But there is nothing wrong with discussing the role of euthanasia in high quality, compassionate end-of-life care. And I vehemently reject the caricature promoted by some CAM advocates of veterinarians who practice science-based medicine as callous and forcing euthanasia on their clients prematurely.   

Veterinary hospice care is a concept that needs to be developed and promoted more widely, and in order to best care for our pets as well as their owners, we need to ensure that the philosophy and techniques that make up hospice care include effective, evidence-based medicine. Offering comfort to clients in the form of therapies that don’t truly benefit our patients is not true compassion, and advocating aggressively for what we believe is the best, most effective scientific treatment available for our patients is not closed-mindedness but conscience. My hope is that conventional veterinary medicine will embrace the hospice concept, and that veterinarians committed to science-based medicine will continue to be involved in its development and implementation so that our pets get the best care possible at the end of their lives.