Nov 07 2017

Science-Based Veterinary Medicine

chiropractic_HorseThe Royal College of Veterinary Surgeons (RCVS) is a UK-based professional organization for veterinary surgeons and nurses. They describe their mission as:

We aim to enhance society through improved animal health and welfare. We do this by setting, upholding and advancing the educational, ethical and clinical standards of veterinary surgeons and veterinary nurses.

They recently came out with a statement regarding complementary and alternative medicine, essentially setting the standard for their profession in the UK. There are some good parts to the statement, but also some dramatic weaknesses which are representative, in my opinion, of the broader issues of how academia is dealing with the CAM phenomenon.

The Case for Science-Based Medicine

Before we get to the statement, let me review my position on the matter. As many readers will likely know, I am a strong advocate for what I call science-based medicine. The SBM approach, at its core, is simple – we advocate for one science-based standard for the health-care profession. This means that treatments which are safe and effective are preferred over those that are either unsafe or ineffective. Effectiveness and safety, of course, occur on a continuum and so individual decisions need to be made based on an overall assessment of risk vs benefit.

Further, the best way to assess the safety and efficacy of an intervention is by a thorough, transparent, and unbiased assessment of the entirety of the scientific evidence. This is where things can get really wonky, which is why specific expertise is required to make such assessments. If you are interested in the details there are a few hundred articles you can read either here or on the SBM website. But here is the short version:

SBM considers both basic science and clinical evidence. The basic science is needed in order to assess the plausibility of any claim or intervention. Further, understanding plausibility (or prior probability) is necessary in order to interpret the clinical evidence. You literally cannot properly interpret the statistical probability of a treatment working unless you know the prior probability, which is dependent upon plausibility.

In addition you need rigorous clinical evidence that shows a specific, consistent, replicable and clinically significant effect of a specific intervention, properly controlling for other relevant variables. Yes, you really do need this. I am not just being persnickety. The evidence clearly shows that when interventions are adopted prior to this level of evidence they are overwhelmingly likely to be reversed with later more rigorous evidence.

We can argue about the exact optimal threshold of evidence we should require before adopting a treatment, but many reviews of the literature and of practice indicate that this threshold should be higher than the current standard in place, and higher than most people think. Otherwise you are more likely to be causing harm than good, and that is the ultimate goal – to make sure we are helping people and not hurting them.

Further, placebo effects are transient and subjective, and do not represent actual improvement in any disease. At best they provide a short term distraction from subjective symptoms. They are not worth pursuing for their own sake, and certainly do not justify interventions which are not science-based.

Given the high stakes within health care, professional ethics requires that we make (collectively and individually) our best efforts to provide science-based interventions, and to avoid the waste and abuse that comes from unscientific claims or practices. Also, the ethical requirements of informed consent and patient autonomy require that we are honest and candid with them about the scientific basis of our recommendations and a realistic assessment of risk vs benefit.

Complementary and alternative medicine (CAM) takes a very different approach. CAM proponents are specifically advocating for a double-standard, one in which a science-based assessment of risk vs benefit is not required. They further seek to weaken and lower the standards of scientific evidence, frequently misinterpret the evidence in a biased manner, make false claims about placebo effects, and favor the freedom of the practitioner over the rights and needs of the patient.

However, there are billions of dollars to be made selling snake oil, and the purveyors of what was previously called simply “health fraud” have invested some of those billions lobbying for favorable laws and regulations, bribing hospitals and academic institutions with donations, setting up their own alternative journals and organizations, and marketing their deceptive narrative to the public.

The RCVS Statement

With this background, let’s take a look at the RCVS statement. They admit that forming their official position was controversial with passionate views on both sides.  That is undoubtedly true, but it is the job of a professional organization to make the right decision, and not cater to a populist insurgency. Unfortunately, it seems that the RCVS caved to pressure and decided to “split the baby.” They begin:

“We would like to highlight our commitment to promoting the advancement of veterinary medicine on sound scientific principles and to reiterate the fundamental obligation on our members as practitioners within a science-based profession, which is to make animal welfare their first consideration.”

OK, so far so good. I like the nod to “science-based.” That is critical, in my opinion. The modern medical profession should be overtly science-based, otherwise we are just witch-doctors. They continue:

“In fulfilling this obligation, we expect treatments offered by veterinary surgeons are underpinned by a recognised evidence base or sound scientific principles. Veterinary surgeons should not make unproven claims about any treatments, including prophylactic treatments.”

Again, very nice. One tweak – I would change “recognised evidence base or sound scientific principles” to “recognised evidence base and sound scientific principles.” As I noted above, you cannot have one without the other.

They then go on to single out homeopathy, which is understandable. Homeopathy has turned into the sacrificial lamb, the one CAM treatment that academics and professionals throw under the bus in order to appear science-based. See – we reject pseudoscience. They write:

“Homeopathy exists without a recognised body of evidence for its use. Furthermore, it is not based on sound scientific principles.”

The very next statement, however, is where they go off the rails.

“To protect animal welfare, we regard such treatments as being complementary rather than alternative to treatments, for which there is a recognised evidence base or which are based in sound scientific principles.

“It is vital to protect the welfare of animals committed to the care of the veterinary profession and the public’s confidence in the profession that any treatments not underpinned by a recognised evidence base or sound scientific principles do not delay or replace those that do.”

Ugh. Given their statement about passions on both sides, I suspect this was their bone to the snake-oil peddlers in their ranks. They bought into the CAM narrative. Essentially they are saying that it is OK to sell pure pseudoscience and nonsense to pet owners, and to subject animals to utterly worthless interventions, as long as they also provide real medicine first. Hey, this way you get to charge for real and fake medicine.

This statement utterly undercuts everything that comes before it. It is also naive to think that resorting to fake medicine is ever benign. As a clinician I can tell you that there is almost never a time when there is nothing science-based to do for a patient. That does not mean we can cure everything, but you can always manage symptoms, improve quality of life, and help your patients deal with their condition.

Giving them fake interventions is always inappropriate, robs them of their resources (financial, time, emotional), gives false hope, betrays their trust and the requirements of patient autonomy and informed consent, and is simply fraud. Sure, it is worse when it replaces real treatment, but in practice this is almost always what happens. “Complementary” or “integrative” approaches are a fiction. When you actually look at what such practitioners do, they incorporate fake interventions early in their management, when science-based interventions are still available. The “complementary” schtick is just a cover.

Also, you simply cannot have an adequate understanding of the relationship between science and medicine and think it is reasonable to give your patient homeopathy or anything similarly pseudoscientific. CAM erodes the public and professional understanding of science, sows confusion, and weakens regulations and professional standards. The RCVS statement is, ironically, evidence of that very thing. Here we have a professional organization whose stated mission is to promote the health of animals with science-based interventions, saying it is OK to give magic water to animals and charge their owners for it.

I don’t know how much this is a failure on the part of the RCVS to recognize the problem, or a failure of political will to deal with it appropriately. It is some combination of both. It is also representative of the broader problem within the general medical profession.

Modern medicine is failing to deal with its own populist and fraudulent insurgency, and it is eroding the profession and our contract with society.

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