One of my favorite encounters with CAM was when a woman brought an old golden retriever to see me because her energy practitioner told her she had detected leukemia, a kind of white blood cell cancer. Though the pet had no signs of illness at all, I ran a number of tests that failed to show any evidence of leukemia. A year later, the pet came back with a slight cough, and again the energy practitioner had told the owner there was cancer, probably in the lung this time. No such cancer appeared on x-rays, and the cough went away when the dog was treated for a bacterial upper respiratory infection. I asked the owner what had happened with the lymphoma that was previously “diagnosed” by her alternative provider. It turns out, not only was the energy practitioner not mistaken, she had apparently diagnosed lymphoma that was undetectable to the scientific methods I used and then cured it with homeopathy and manipulation of the patient’s energy.

Now this is fun all by itself. The quack will predict that an old golden retriever has cancer every year. Whenever the prediction is wrong, the energy healer will get credit for preventing the disease. But, sooner or later, the dog probably will get cancer, since it is a common disease in the aged and in that breed. When that happens, she’ll get credit for predicting it, and probably for palliating its symptoms and delaying the course. How do you get a racket like that?!

But, more seriously, this raises the question of how decide what screening tests to run in a given patient. Running bloodwork to look for leukemia in a symptom-free animal is pointless. The disease isn’t common, and it’s usually rapidly progressive so it makes the patient sick pretty fast. Testing clinically normal animals won’t likely find any leukemia cases, and it also won’t guarantee that the animals we test won’t get leukemia next week. It’s probably a harmless waste of $45 since the risk from drawing a blood sample is negligible, but it’s still unnecessary.

It is generally of questionable value to run screening tests blindly in apparently healthy animals. A study in Germany1 looked at bloodwork taken prior to anesthesia in over 1500 dogs and found that “the changes revealed by pre-operative screening were usually of little clinical relevance and did not prompt major changes to the anesthetic technique…In dogs, pre-anesthetic laboratory examination is unlikely to yield additional important information if no potential problems are identified in the history and on physical examination.” The study did show, however, that there were some “abnormal” results, and if those results led to delay in surgical treatment or to unnecessary diagnostics, then there could potentially be a cost to such screening.

In fact, sometimes the costs of tests that are not indicated by some specific clinical suspicion can be quite high. A recent study in the Annals of Family Medicine, covered in more detail on the Science-Based Medicine blog, found that the cumulative risk of undergoing unnecessary invasive diagnostic tests as a result of false positive results in several common screening tests for cancer was 29% in men and 22% in women over 3 years. These people had to cope with the anxiety of thinking they might have cancer, and with the risks of invasive diagnostic tests, when in fact the screening test was wrong. Harriet Hall has done a fine job of illustrating the same problem with screening asymptomatic patients in her discussion of prostate cancer and the PSA test. As with all things in the real world, benefits come with risks, and an appropriate balance between the two comes only from careful study and constant re-examination and revision of clinical practices.

Certainly screening tests, properly used, can save lives. But such tests are seldom as definitive as the public tends to think, and they are not without their risks. At least, in scientific medicine, an effort is made to determine when such tests are indicated, when their benefits outweigh their costs. In CAM, this is rarely the case. Chiropractic booths offering free spinal screenings are ubiquitous at county fairs, farmer‘s markets and other such venues, and shockingly every single person who gets “tested” turns out to have something that needs fixing. CAM practitioners are remarkable in their ability to find problems in apparently healthy patients. But as the anecdote I started with illustrates, they have some advantages over science-based medicine when it comes to such screening tests.

If you apply a CAM test to a healthy patient and find a subluxation, unbalanced Ch’i,
or some other result that no one else can confirm or deny, you may create some anxiety, and you will very likely expose the patient to the expense, and sometimes risk of treatment. But ultimately you can do whatever magic you do, declare the patient cured and the follow-up test results normal, and your client will likely thank you. You will certainly never have to face the awkward situation of not being able to find a lesion, and having the patient of pet owner decide you must be incompetent because they “know” something is wrong. And you will never have to agonize over whether running the test in the first place will do more harm than good, or whether false positive results might lead you to perform ultimately unnecessary diagnostics or treatments. And, as I’ve suggested before, you will have the advantage of a satisfyingly simply and clear narrative to offer, with no uncertainties. Yet another example of how CAM practitioners avoid the whole unpleasant issue of truth and fiction, and manage to make clients happy and themselves a nice living without all the bother of the constant questioning, self-doubt, and paradigm revision of real medicine.

1. Alef, M.,von Praun, F., Oechtering, G. Is routine pre-anesthetic haematological and biochemical screening justified in dogs? Vet Anesth Anal 2008; 35:132-140.

The Evidence-Based Veterinary Medicine EBVM Conundrum

“Dr. X said that one of his main purposes when discussing EBM/EBVM at meetings is to get students/practitioners to question their decisions (i.e., to be less certain about decisions they make). This invariably results in “push back” from some attendees, because they go to meetings in hopes of coming away with answers/information; not more doubt and indecision. In human medicine, they do not have that problem. Once a physician’s misled belief in old stereotypic (non-evidentiary) information can be torn down, they can readily be remolded along EBM lines because there is plenty of valid EBM results published. On the other hand, there is a paucity of hard-core EBVM studies in the literature, and without significant funding this trend will continue in the foreseeable future. However, that should not diminish the effort… to get students and practitioners to understand that what they learn and later practice as practitioners is based on this paucity, to factor that into their decision processes, and to demand more valid studies based on the principles of EBM.

Another point made was that students, in particular, have the misguided belief that consensus is evidence. This belief needs to be dispelled.”

The above statement was made in the context of developing projects and goals for an organization striving to promote evidence-based medicine within the veterinary field. It struck me as identifying a key problem for those of us in the field trying to change the culture of veterinary medicine to be more focused on scientific, evidence-based medicine EBM) and less on the “art” of medicine, by which we usually mean the following of hunches and intuition by doctors.

Of course, the first step towards recognizing the values of EBM is acknowledging the limitations of our own abilities to assess our patients’ clinical problems and responses to our interventions. This is challenging enough as it directly threatens our sense of knowledge and competence. Doctors often caricature EBM as a painting-by-numbers approach to medicine, where the doctor is a mere robot following the pre-programmed algorithms produced by some faceless research bureaucracy. This image speaks to the depths of the fear clinicians have about acknowledging the unreliability of their own judgment in the face of the vast body of information that constitutes modern medical knowledge and the dazzlingly complex organisms that are our patients.

I believe this fear is unfounded, as the need for and value of intelligent, talented, and hard-working people is not diminished by EBM. It is simply a tool that replaces our best guess with real information. But the fear is understandable and powerful, and must be addressed if EBM is to make any headway among veterinarians.

But the EBVM Conundrum speaks to a problem that lies in wait for us after we have faced the already daunting task of instilling a greater sense of skepticism about our own wisdom and abilities in vets. What body of reliable science and evidence-based information are we to use as a replacement for our intuition and experience? There can, of course, never be enough good clinical data, and some level of uncertainty will always remain to be bridged by individual judgment. But in veterinary medicine, we are particularly blighted by the lack of well-designed and well-conducted clinical research. This is primarily an economic problem, though the culture of veterinary medicine plays a role.

Funding such research often requires the deep pockets of industry or government. And while industry does support a lot of veterinary research, the profits to be made are miniscule compared to those in the human medical field. And industry money doesn’t come without an agenda which can influence the direction and results of research. Even with rigorous controls and the best of intentions, it has been clearly demonstrated that the source of funding has a consistent and significant impact on the outcome of clinical studies.

And the political climate has long been unhealthy for government sponsorship of independent research even in human medicine. Veterinary medicine cannot expect much public sector support of such research except in those areas that are, or can be made to seem, directly relevant to human health concerns.

The news is not all bad, of course. Some good quality veterinary clinical and basic research is done and published, funded by academia, private foundations, industry, and the others. And, with a wealth of necessary caveats, research already done concerning human health issues can provide some useful guidelines. At the least, such data can help us be wise in how we use the limited resources we have. If decades of extensive research in human medicine have revealed nothing of value in prima facie unlikely therapies such as homeopathy, therapeutic touch, acupuncture, and the like, we would be smart to take the lesson and not spend too much effort and money demonstrating the comparable lack of utility for such methods in veterinary patients.

There are many individual veterinarians, and some institutions with veterinary medicine, that see the medical and economic benefits and the practical and philosophical, and ethical value of making veterinary medicine a truly evidence-based, scientific enterprise. And these agents are contributing to the realization of this goal despite the obstacles I’ve discussed. As the opening statement points out, changing the culture among veterinarians to be more accepting of our own limitations and of the need for the tool of EBM is necessary part of the process of developing the solid, evidence-based guidelines clinicians need. And identifying such problems as the EBVM Conundrum improves our ability to plan how best to move the veterinary medical field in this direction.

Peter Lipsom has written a concise and insightful post at the Science-Based Medicine Blog, entitled The Death and Rebirth of Vitalism. It illustrates why the underlying philosophical position of faith-based medicine is unteneable. Magical entities, such as Ch’i in acupuncture, Innate Intelligence in chiropractic, Water Memory in homeopathy and so on, are required by CAM practices that cannot demonstrate plausible rationales by mainstream scientific methods. This contrasts with the Methodological Naturalism required by science, and the true philosophical naturalism and materialism many scientist accept as the truth about the nature of the universe.

As the comments that follow the post illustrate, pointing out the intellectual bankruptcy of the philosophy behind most CAM approaches can lead to resistence against science-based medicine even among scientists and people not otherwise sympathetic to CAM. This is at least partly because looking at the underlying philosophical and epistemelogical distinctions between science-based and faith-based medicine can lead to awkward questions about other faith-based beliefs.

The human mind is miraculous in its ability to hold contradictory ideas at the same time, so many scientists can go about their lives practicing methodological naturalism while believing in the eternal soul, reincarnation, or other non-material entities without trouble, so long as the conflict isn’t shoved in their faces. When it is, some attempt to work out acceptable philosophical compromises, such as Stephen Jay Gould’s Non-Overlapping Magisteria approach. Others simply choose faith over reason and most simply decide not to dwell on the issue. A few, think and read and meditate deeply about the controversy and elect to try and extend their professional naturalism into all areas of their lives. As far as I’m concerned, these are all fair and legitimate responses to a tough question.

But what is not legitimate is when the challenge to faith in areas outside of science is so threatening that scientists choose to let go of their methodological naturalism and embrace faith-based medicine uncritically. Not everyone cares to conduct difficult and complex investigations into the philosophical underpinnings of theri work or their personal life, and this isn’t by any means a requirement for a productive life in science or medicine. I happen to think it can enrich anyone’s life and work, but that may just be my personal intellectual tastes. However, when it comes to the material world, which includes the bodies and minds of our patients and the tools with which we treat them, there are right and wrong answers. Vitalism may stumble on the right answers by accident from time to time, but science and methodological nauralism consistently get the answers right far more often. To ignore this and cling to faith-based medical practices simply to avoid uncomfortable questions about other deeply held faith-based beliefs is intellectually dishonest and not in the best interests of our patients.

There are many reasons why therapies which don’t actually have a physical effect on a disease may appear to work anyway (an extensive list of which can be found under Can We Trust Clinical Experience? at my website). One of the best known, and misunderstood, is the so-called Placebo Effect.

Though this is generally used to mean any positive effect of a treatment that isn’t actually affecting the underlying disease, it really should apply more narrowly to perception-mediated non-specific effects of a treatment. In humans subjective perception of discomfort (pain, nausea, anxiety, etc) often improves with any treatment, and this seems to be largely due to the effects of expectation, diversion of attention, and classical conditioning. Objectively measurable physical parameters can be altered by the placebo effect, but disease progression and outcome are not.

In animals, the influence of expectation and diversion of attention do not seem to play a role in the placebo effect, but nonspecific effects of ineffectual treatments are seen. One possible reason for this is classical conditioning. Dogs exposed to food and a ringing bell can be conditioned not only to salivate and look for food but to secrete stomach acid when the bell is rung. Animals repeatedly given insulin injections, which lower blood sugar, can then manifest a decrease in blood sugar when given a saline injection. So the experience of feeling better after receiving true treatment for disease in the past could possibly condition a mild, transient improvement from the same treatment environment in the absence of a truly effective therapy.

There are other possible explanations for a placebo-like effect in veterinary patients (stress hormone release associated with the vet visit, changes in owner management during a period of concern, etc). Probably the most significant, however, is what I call the “placebo effect by proxy.” Owners have a strong desire to see their pets get better. They also have a desire see the worry and expense of a vet visit validated by improvement. Confirmation bias, cognitive dissonance, and old-fashioned wishful thinking can all make therapies initially seem to work even when they are doing nothing. And in cases where other factors such as regression to the mean of chronic symptoms, spontaneous resolution of disease, and misdiagnosis lead to a true resolution of the complaint, useless therapies may seem to work, the patient will get better, the owner will be happy, and the vet will get the credit. So what’s wrong with that?

Well, for one thing taking advantage of a direct or proxy placebo effect requires deception. The patient or client must believe they are being given a real therapy. In fact studies have shown that the more confidence with which a doctor presents a placebo to a patient, the more effect it has.

Introducing deliberate deception into the medical relationship strikes me as an ethical and practical quagmire. As a vet, people trust me to do painful, costly things they don’t always fully understand to their family members. This trust requires that I be honest with them, and there is no effective way to do this and still utilize therapies I believe to be ineffective. At best, I could say, “Treatment X has not been proven to be beneficial but anecdotally some people have reported a positive response…” Such a weak presentation would likely diminish the desired non-specific effects while not really solving the ethical problem.

In the veterinary setting, the placebo is likely working much better on the owner than the patient. So while I might get some undeserved credit for a bogus treatment, the patient is still suffering. And since not all placebos are without risks (such as the still apparently common practice of prescribing antibiotics for viral infections), utilizing them can even present a small risk of doing harm for no true benefit in terms of the disease, regardless of whether the patient or client perceives a benefit.

I once denied a client a prescription for antibiotics for their cat, who had bloody urine. The particular circumstances indicated the cat had a vanishingly small chance of having a bacterial infection (no more than 2% in one study), while the incidence of vomiting, anorexia, and diarrhea from the antibiotic was much higher (about 10-15%). The clinical signs in such cases usually go away by themselves in about 7 days. The client was irate and went to my boss, who gave her what she wanted.

When I challenged him for doing so, I pointed out that he would get credit for solving the problem when what he had done only satisfied the owner, did nothing for the pet, and exposed the patient to an unnecessary risk. He felt that if the pet got better, the client was happy, and he got the credit it was a win for everybody, and he couldn’t see any ethical dilemma. He was also a much older doctor who had trained at a time when human medicine still followed the paternalistic model, doing what the doctor thought best without regard for the patient’s wishes. That model has been rejected by mainstream human medicine, and it has not place in veterinary medicine either.

It is common for vets and doctors who are not believers in alternative therapies to utilize them anyway because they make clients or patients happy. These providers generally rationalize this by saying that the risk is low (which it generally is) and that a true benefit is at least possible (which it often is not). However, they fail to include in this calculation the risks, and the raw ethical problem, of deliberately deceiving the client or patient. And they ignore the very real practical problem of encouraging belief in ineffective or unproven therapies and the epistemological and philosophical paradigms that often accompany them, and which are generally very anti-scientific.

While there is always some uncertainty about the risks and benefits of any treatment in a given clinical situation, and while honesty does not always require a lawyerly detailing of these that creates pointless anxiety, using clearly disproven approaches, and even implausible treatments that have not been thoroughly tested, requires us to violate the trust our clients and patients give us for a superficial and transient benefit, which in the veterinary setting does not even apply to the actual patient. It may be more difficult to deserve this trust with sometimes uncomfortable honesty, but I am convinced this is the right path to take, ethically and practically.

The mainstream media has always had a problem covering complementary and alternative medicine (CAM). It’s much like the problem they have covering the arguments about teaching evolution or creationism in public schools. The training of journalists to “tell both sides” of every story makes them try to present representatives and their points of view on two sides of any issue as if they were essentially equivalent. This may be an attempt to achieve objectivity, but without context it creates the erroneous and misleading impression that there is merely a difference of opinion among “experts” rather than a solid body of evidence and theory on one side (evolution, scientific medicine) and a relatively small cadre of faithful believers with little evidence to support their position on the other (creationism, CAM).

The media also likes a good David and Goliath story, and tends to cast the CAM community as small scale healers struggling to bring safe, natural remedies to the suffering against the opposition of large-scale, rich, corporate and academic machines trying to maintain their lucrative monopoly on the maintenance of illness. This ignores the truth of many hard-working, compassionate, and underpaid health care providers and many large-scale, wealthy supplement and alternative care industries, but it makes a more compelling narrative.

Lately, though, there have been a few small, encouraging signs that mainstream reporters can cover the issue of CAM in a way that accurately illustrates reality. Newsweek recently ran an article exposing the dangerous faith many of Oprah Winfrey’s viewers have in her opinions and those of the CAM “experts” (like actress Suzanne Somers) that she regularly promotes through her various media outlets (Live Your Best Life Ever).

Making the case that Oprah has a tremendous influence on people’s opinions and behavior, and that this should entail a responsibility on her to give truthful, accurate information, is a clear and cogent way to make an important point about unproven CAM approaches without in any way being biased on unfair.

Newsweek also ran an article in October, 2008 reviewing very generally reviewing the evidence for and against some popular CAM therapies (The Truth About Alternative Medicine). While the treatment of the evidence was somewhat superficial, the fact that the article emphasized looking at CAM in the same evidence-based way we look at mainstream medical practices is a step in the right direction.

Finally, Marilynn Marchione, a medical writer for the Associated Press, has written a couple of very sharp pieces recently pointing out that CAM is both very widespread and often not as safe as it is believed to be. (Alternative Medicine Goes Mainstream and 60 Pct of Cancer Patients Try Nontraditional Med)

I can’t remember the last time a mainstream media writer pointed out the naturalistic fallacy!

CAM advocates have a number of marketing advantages, and have made some smart strategically choices in how they characterize themselves and the medical mainstream, and science-based medicine is having to face the reality that being right about the facts is seldom as important in making a convincing argument as we’d like it to be. What media experts call “framing” is an important strategy, and these articles illustrate ways the debate can be framed that illustrate the true dangers of unquestioning acceptance of CAM and the importance of verifiable facts in making health care choices, while still remaining fair and open-minded. Let’s hope we see more of the like!

One of the great marketing advantage complementary and alternative medicine (CAM) has over mainstream science-based medicine is the appeal of simple explanatory narratives. Sometimes we get to take advantage of this in scientific medicine. Bacteria cause infections, antibiotics kill bacteria and the infections go away. This is a simple, satisfying story that can be told in a 25 or 30-minute office visit, and it gives the pet owner a sense that they understand the problem and the solution. But sadly, real life, and real medicine, isn’t always that clear cut.

Explaining the pathogenesis of cancer, or Cushing’s disease, or some idiopathic condition we don’t yet fully understand can be very frustrating for the vet and the pet owner. Without a clear and comprehensible description of the problem, and without a straightforward treatment or prognosis, the client begins to doubt the competence of their vet.

One of the best indications that many CAM approaches are not correct is that they seem never to face this problem. A chiropractor can always find a subluxation to blame for back pain. And if there is no pain, why that’s because the subluxation was corrected before it got bad enough to cause symptoms!

Homeopathy has a consistent and appealing narrative in the Law of Similars. This says that miniscule amounts of a substance which causes a symptom (or merely the energetic resonance left behind by the substance after it has been diluted away) can actually remove the symptom from the patient. The fact that this makes no physiologic sense, that most homeopathic remedies haven’t undergone “provings” to see if they can cause the symptoms they are used to treat, and that clinical trials have shown the stuff doesn’t work anyway is irrelevant. There is always a ready answer and a ready solution with a simple link between the two.

Unbalanced Ch’i or yin/yang, mysterious “toxins,” vertebral subluxations, and many other such entities all share some essential characteristics that make them appealing and persistent as explanations for disease.

They are unfamiliar to most people since they can only be identified by specially trained practitioners. This gives them a mysterious and sinister aura that makes it easy to inspire worry about their malign effects in people’s minds. Infectious agents don’t fit the role of villain nearly as well since people have come to expect, through the hard won success of vaccines and antibiotics, that if these were really the causes of their problem doctors should be able to find and eliminate them with no trouble. And complex sources of disease such as the multiple genetic and environmental and random chance effects spread out over decades that lead to most cancers are not sufficiently clear and circumscribed causes to fill the role of villain, nor can the practitioner of scientific medicine claim to be able to easily identify and vanquish them.

The sources of disease claimed by many CAM methods also share the characteristic of being ephemeral and not amenable to consistent, objective. Chiropractors almost never agree with one another about where the dreaded subluxation is, and homeopaths seeing the same patient seem to come up with widely different assessments and prescriptions. This seems like it should be a disadvantage to those of us accustomed to the scientific notion that one must clearly establish the objective reality of something before blaming disease on it. But actually the intangible quality of these etiologies makes them perfect villains. The CAM practitioner can always find them when they need an explanation for something, no one can gainsay this explanation since there is no objective standard for verifying the diagnosis, and if the patient gets better the practitioner can claim the cause is no longer there, again without any fear of being proven wrong. Sadly, in science-based medicine we are much more often forced to honestly admit when we cannot find the cause of a patient’s symptoms, we cannot ethically prescribe a treatment without some legitimate indication, and we can’t automatically claim the credit for improvement.

People desperately want simple, clear explanations for what is wrong with their pets. They want to know what the chances are of the problem getting better. And they want to know what needs to be done. All of these things allow the pet owner to either feel more in control of the scary thing that is happening to their pet, or at least to adjust their expectations and emotions to the inevitable. What people do not want is to be told that the cause of their pet’s illness is unknown, that the doctor cannot say with certainty what will happen, and that any treatment is an educated guess at best. To be fair, I have seen some CAM practitioners admit to not knowing what is wrong or to not being sure if their treatments will work. But far more often, where the science-based medical approach calls for painful honesty about the uncertainty involved, the CAM approach allows for confident, simple explanations of the problem and confident treatment recommendations.

Not being tied to an objective, verifiable physical reality, many CAM approaches can give people what they want and need emotionally when their pets are sick, even if they can’t actually offer anything of benefit to the patient. This is an advantage in terms of appealing to the public that scientific medicine cannot co-opt or undermine. Of course, scientific medicine often has the advantage of being right about the real causes and the appropriate treatments, and this often trumps the lack of appealing simplicity in scientific explanations. Very few CAM therapies have established themselves as popular treatments for acute, life-threatening diseases because they simply cannot compete with scientific medicine in terms of results. But when it comes to the vague and the chronic complaints that science does not yet have clear answers to, and for which indeed there may not even be clear answers to be found, we shall have to accept the disadvantage of being honesty about the complexity and uncertainty of these conditions. It is the price paid for holding out for real answers rather than simple, appealing, but ultimately empty stories.