In addition to substantive arguments about evidence, clinical studies, and underlying biological or physical rationale, many arguments between supporters and skeptics of veterinary CAM involve myths, stereotypes, logical fallacies, and other rhetorical devices or conceptual errors unrelated to the actual merits of the case being made. The recent discussion in response to Narda Robinson’s article on the Pet Connection Blog has revealed some of the archetypical forms of these, and I thought I’d offer a few possible responses.

1. Argument from Faith-

This, of course, underlies much CAM. Supporters “know” things work because of their firsthand experiences or they have faith in the wisdom of tradition or individual gurus. Apart from the cognitive errors that make anecdote and firsthand experience rather unreliable, the propensity for self-validating belief is a problem in itself. Faith is, by its very nature, self-reinforcing. Belief begets belief, and humans are notoriously loath to give up beliefs regardless of evidence. We hate to have to accept the ambiguity and uncertainty of knowing our personal impressions are less reliable than the objective and impersonal process of science. There is a powerful psychological incentive to reject evidence-based medicine because it takes away our illusions. Supporters of CAVM can claim that because they have believed and practiced these methods, because they have “seen for themselves,” that their wisdom and position of authority must be respected. Sadly, their intelligence and passion and conviction may make them convincing to others, but they don’t make them right. Only well-designed and conducted research which take the biases of passion and conviction out of the evaluation process can prove their case, and they often disdain such because it seems to them beside the point, a mere frill to “prove” what they already “know.”

The emotional intensity of true faith also contributes to the tendency of CAM supporters to perceive disagreement as disrespect, or to act as if respect ought to be a substitute for evidence, but such is the nature of faith-based medicine.

While we should be free to disagree about facts, I find CAM proponents often identify disagreement with suppression of the truth, ignorance, or some sort of political conspiracy. This is part of the David and Goliath Myth I’ve written about before. I try to take their belief in the benefits of the methods they espouse in good faith, and I believe they have their patients’ best interests at heart. Mature and respectful disagreement requires that they treat dissenting opinions likewise because their belief is often a matter of personal faith, they can be quick to dismiss other opinions as disingenuous or motivated  by something other than the best interests of our patients.

2. Tu Quoque Fallacy

There are several versions of the “you too” argument. One is that mainstream medicine is itself not evidence or science based and so CAM has an equal claim to legitimacy and efficacy. The specific citation that “only 15% of allopathic medical treatments were based on scientific studies” has been well-debunked.

There is a grain of truth to this assertion. Many mainstream practices have been “grandfathered in” (as, I might add, has the US Homeopathic Pharmacopeia, which was automatically exempted from proving safety and efficacy when food and drug safety laws were instituted in the U.S.). These practices do not have the level of evidence behind them they would require if newly discovered today. However, the level of evidence behind mainstream medical practices is far higher than for alternative practices. And the underlying principles are not grossly inconsistent with established principles of the biological or physical sciences, as is often the case for CAM methods. And rather than considering centuries or millennia of unquestioned use to be a point in favor of a therapy, as does the CAVM community, scientific medicine holds all practices as open to criticism based on logic, reason, general scientific principles, and of course clinical evidence.

Another fallacious form of this argument says that because mainstream scientific medicine makes mistakes and there are bad doctors in scientific as well as alternative medicine, that this is somehow evidence in support of homeopathy, TCM, or other alternative therapies. There is no connection. Scientific medicine makes mistakes, but science is always changing and improving and these mistakes eventually get corrected. Scientists are imperfect human beings, but the scientific method applied over time but many individuals compensates for our flaws. Therapies based on unwavering respect for ancient traditions and validated primarily by personal experience and belief, on the other hand, have no reason to seek and correct mistakes. If Palmer and Hahnemann and the ancient Chinese physicians had it right, then our duty is to follow their advice and not question or challenge it. Western mainstream medicine made this mistake in canonizing Galen and the other Greek physicians and accepting without question both what they were right about and what they were wrong about. And medicine stagnated in a miserable state for centuries. The scientific method changed that and made active questioning and critique a virtue. I know some CAM proponents will disagree and say that we are all drowning in toxins and disease and that the pre-scientific age was a Golden Age, but the history of the succeeding couple hundred years suggests to me that the scientific approach works much better.

In any case, the lack of perfection in scientific medicine is not an argument that no progress has been made or that the method doesn’t work. And it’s certainly not an argument that the exact opposite philosophy is the better alternative.

3. Health Care Choice

A popular defense of CAM in the U.S. these days if the argument that consumers (not “patients”) should be free to choose what kind of health care they want, apparently regardless of whether it works or not. The “free choice” argument is a popular strategy as it plays into the general cultural suspicion of government and the respect for individual freedom. But the “choice” between methods which help and those which do nothing or even harm a patient is not a truly free choice. If one accepts that the government has any role at all in protecting public health, than one has to accept that establishing some reliable and objective standards of safety and efficacy is an appropriate government activity. If, of course, you believe government should stay out of everybody’s business altogether, than you won’t accept this, but that’s really a political not a scientific debate. There is a segment of the libertarian movement that aggressively supports CAM for clearly political reasons, though thankfully there are also many solidly skeptical libertarians as well.

History suggests to me, that the methods of science are better at determining safety and efficacy than tradition and personal experiences. For a thousand years doctors and patients believed bloodletting, purging, cupping, casting out demons, and lots of other non-scientific method of treatment were helpful. Those people were just as smart as we are, but they had the same flaws and cognitive vulnerabilities. We now live longer and healthier lives and eschew those methods because we have developed a better way to determine what works and what doesn’t. This is not cultural chauvinism, it’s just a pragmatic evaluation of reality. And if this is true, then a caveat emptor approach to health care where we are “free” to choose whatever snake oil is sold to us, and the salesmen are free to claim whatever they like without reasonable proof, seems a step backwards and a guarantee of much unnecessary suffering.

The history of government regulation of food and drugs shows some real benefits to limiting the medical therapies that can be made available to those which have some reasonable, scientific plausibility, and the weakening of such laws through legislation such as the 1994 Dietary Supplement and Health Education Act have clearly led to harm, and this argues against the benefits of so-called “health care freedom.”

This is an insightful essay illustrating the ultimately faith-based nature of much CAM. Statements about safety and efficacy and the indications of a treatment are determined by tradition, appeal to authority, or instinct and then justified by anecdote without any objective supporting evidence. What I find as informative as the essay are the voluminous comments, including from the legendary CAVM guru Dr. Pitcairn, illustrating how passionate people become when you suggest that their intuition and personal experience, their faith, may not be a sufficient justification for medical recommendations that don’t have any other evidentiary basis. Enjoy!

CAM proponents often present a picture of the relationship between CAM and mainstream medicine that is as dramatic as it is fanciful, and it bears a resemblance to the myth of David and Goliath. Scientific medicine is portrayed as a venal cabal of big corporations and corrupt government bureaucracies determined to maintain a lucrative monopoly on health care by suppressing safe and effective, but unprofitable natural cures such as herbs, homeopathy, acupuncture, chiropractic, reiki, and so on. CAM, in contrast, is portrayed as a loosely-affiliated network of individual healers all dedicated to promoting health and well-being and to bringing people the freedom to choose their own path to wellness outside the rigid and coercive structures of government, the Cancer Industry, Big Pharma and the rest of the nefarious medical-industrial complex.

Like most myths, this one contains a few grains of truth amidst the chaff of fantasy and marketing. The pharmaceutical industry, for example is enormous, wealthy, and driven primarily by profit. While there are many individuals working in pharmaceutical and biotechnology research who are dedicated to relieving suffering through science, the institutions exist as entities of the market, and as such they often prioritize their efforts based on profitability, and they often work vigorously to manipulate health care providers, consumers, and government in ways that have more to do with return on investment than promoting health and welfare. Any corporate, for-profit company must consider making money a goal or it ceases to exist. This is true for pharmaceutical companies veterinary hospitals, and — hey, wait a minute. It’s true for herbal medicine manufacturers, dietary supplement companies, chiropractors, acupuncturists, and all those CAM folks too!

Reliable figures are hard to come by, but there’s no doubt CAM is big business. In 2005, consumers spent more than $21 billion on supplements in the U.S. and $66 billion worldwide, according to the Nutrition Business Journal (1). One study estimates total annual CAM sales at £4.5 billion in the UK, $2.4 billion in Canada, and $80 million in Australia.(2) Many of these supplements are sold by corporate giants such as Herbalife (2008 earnings $2.15 billion) and GNC (2008 earnings > $16 million). And even 10 years ago mainstream pharmaceutical giants were getting involved in the vitamin, supplement, and herbal products market, and this involvement has only increased. Most veterinary herbal and neutraceutical products are manufactured by the same pet food and drug giants the CAM community so derides. So in many ways, Big Pharma is Big CAM.

The image of alternative medicine providers as individuals fighting to practice and tell their side of the story against the organized opposition and censorship of mainstream medicine is also disingenuous. The supplement and herbal medicine industry is highly organized and has a vigorous, well-funded lobby that has successfully fought government attempts to regulate their products in a way comparable to other medicines on the market. The United Natural Products Alliance and the Council for Responsible Nutrition are among the biggest supplement industry advocacy and lobbying groups, and they have aggressively and successfully supported a fox-guarding-the henhouse strategy of industry self-regulation and opposed government attempts to require published evidence of safety and efficacy for their products.

Chiropractors are also highly organized, well-funded, and politically active. They successfully defeated the efforts of the American Medical Association to curtail the acceptance of chiropractic as legitimate by government and the health insurance industry. After organizing to defend individual chiropractors against injury lawsuits, the chiropractic lobby supported a successful anti-trust lawsuit which has left the AMA very reluctant to oppose the spread of chiropractic despite its poor evidence of efficacy and its very real risks. (3)

And in the United Kingdom, The British Chiropractic Association has successfully pursued a libel lawsuit against Simon Singh, a journalist who wrote an article in the Guardian Newspaper critical of their promotion of chiropractic for childhood asthma, colic, and other conditions for which chiropractic is proven ineffective. Hundreds of thousands of pounds have been spent by the chiropractic lobby suppressing the evidence-based opinion of one journalist in one newspaper article. This is hardly consistent with the image the industry promotes of itself as the well-meaning and plucky underdog.

CAM proponents often complain about the resistance to their ideas in academic institutions, and portray themselves as inheritors of folk tradition and wisdom that does not require academic validation. Yet they aggressively promote their agendas in these same academic institutions and set up their own credentialing and degree programs to take advantage of the legitimacy and respectability conveyed by the imprimatur of academic institutions they disdain.(2) And while CAM proponents talk about “health care choice” and keeping government out of the business of regulating the claims of health care products, they have successfully supported spending over $1 billion of taxpayer money through the National Center for Complementary and Alternative Medicine at the NIH on research which has yet to validate and clinically significant CAM therapy.

So while the CA as David and the Medical/Industrial Complex as Goliath marketing strategy has been creative and effective, it is not an accurate portrayal of reality. In both CAM and scientific medicine, there are mostly hard-working people genuinely dedicated to relieving suffering. And in both areas, there are venal and unscrupulous individuals seeking money, fame, and other self-serving goals. This has no bearing on the issue that should be the center of any discussion about CAM and science-based medicine, which is what works and what doesn’t. The David and Goliath frame is a fantasy designed to distract from the realities of the evidence and to shield the CAM industry from the scrutiny and supervision mainstream medicine is expected to undergo.

1. Hurley, D. Natural Causes: Death, Lies, and Politics in America’s Vitamin and Herbal Supplement Industry. Broadway Books, New York. 2006.

2. Shapiro, R. Suckers: How Alternative Medicine Make Fools of Us All. Vintage Books, London, 2008.

3. Ernst, E., Singh, S. Trick or Treattment: The Undeniable Factts About Alternative Medicine. W.W. Norton & Company, New York. 2008.

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.