Thursday, June 11, 2009
Monday, February 2, 2009
Should Complementary and Alternative (aka Integrative) Veterinary Medicine be taught in vet schools?
The core of today’s veterinary education has, for good reason, been built upon a vast web of interconnected and established science. With this in mind, the belief in the need to teach Complementary and Alternative Veterinary Medicine (CAVM) at veterinary schools immediately brings to the fore a looming dilemma.
Science is a powerful filter and provides a foundation from where medicine has discovered truly effective therapies. It has proven an excellent tool for excising the useful from the useless (i.e.; statistical significance vs. fanciful testimony and tenuous beliefs). To date, science is the only way to assure that medicine stays on the straight and narrow and optimizes its effectiveness. Without it, no matter how well intentioned, the practice of medicine falls prey to a world of delusion and fairy tales.
Medicine develops and refines innumerable modalities and therapies based on accumulating evidence. Though this evidence may vary in robustness and quality it is always grounded in science. In general, you can’t skip over this basic filter and practice any kind of “medicine” that suits your fancy- that usually leads to the realms of metaphysics and belief.
The machinery for seeking and establishing effectiveness in medicine assumes the plausibility of what is being studied. If it is not a plausible modality the best the research can offer is often just garbled noise -equivocal statistical data- that is neither here nor there. This is something novice students are not being taught and herein lays the problem.
Medical education needs to emphasize critical thinking tools and teach aspiring doctors how to navigate within the depth of established science based medicine before tackling fringe areas such as alternative medicine.
If a student sees a CAVM modality as part of the curriculum of veterinary education the assumption is made –whether these young minds know it or not- that there must be something to this particular practice. It falls under the rubric of an accepted standard of practice and therefore is a part of general practice. This simply is not the case because if it were there would be no “alternative” in alternative medicine.
When it is implicit to students that academia tolerates alternative medicine as “just another way” you compromise these students science based education. Dr. Colquhoun points out that “Once any treatment is shown beyond doubt to be effective, it ceases to be ‘alternative’ and becomes just like any other part of medical knowledge. That means that ‘alternative medicine’ must consist of unproven treatments.” It is not the domain of academia to be teaching unproven treatments to young students.
Introducing unsubstatntiated non science based modalities and therapies that might have some plausible basis (acupuncture), no matter how scientific they might appear, to these aspiring professionals before they are ready to critically evaluate them is a bad idea. It opens the doors to a Pandora’s Box as other alternative medical paradigms (i.e.; homeopathy, energy medicine) will inevitably also demand a place in academia.
This is reminiscent of “teaching the controversy” of evolution that intelligent design advocates support so vehemently. This red herring demonstrates an alarming lack of actual scientific knowledge regarding proper methodology and smacks of dogma and pseudoscience.
Dr. Colquhoun points out an interesting observation with respect to the curious confounding of pseudoscience and science ("quackademics") in medical schools. He states that “All these outfits have two things in common. They all claim to be scientific and evidence- based, and none has produced any real evidence that any of their treatments work.”
This is one of the weaknesses to claiming that the CAVM offered in veterinary schools is being scrutinized under the framework of science. If they were, they would be pulled out of the cirriculum or possibly relegated to research. As noted though, you can't use evidence-based research very well when the underlying science is suspect.
In addition, the fact that CAVM has become a fairly popular practice among some people and practitioners outside academia is not an excuse to teach it in school. This is an appeal to popularity and gets medicine no-where.
It has been noted that veterinarians need to be more non-judgmental and not stigmatize CAVM; implying a rush to judgment and a bias against CAVM. In some cases, the implication goes; this may threaten a client/doctor relationship and could lead to the loss of clients who might move entirely to alternative medicine. Medicine needs to “adapt to changes brought about by societal influence” and the popularity of CAVM –another effective way of doing medicine- needs to be accepted, embraced, and taught in school. This is threading misrepresentation with populism- a dangerous mix.
Fallacious reasoning like this creates false realities and gives little credence to the ability of a skilled practitioner and the influence they can have on client/doctor relationships. The opportunity to communicate and teach science based medicine is taken seriously my many practitioners.
They feel obligated to create a comforting, supportive, and trusting bond that openly and honestly approaches the situation at hand. Practicing the best science and evidence based medicine they can goes hand in glove with this bond and most clients will respect that.1
Though, there may be emotionally charged biases against CAVM at times, the fact remains that -for the most part- it is not science and it is definitely not a substantiated medical modality. Disregarding or not recommending CAVM if it does not fulfill the requirements of science and evidence based medicine is not being biased.
Learning how to communicate and interact empathetically with people is by far one of the most important skills a veterinary student can learn. This is what should be stressed more in university curriculums than teaching pseudo-science. On the other hand, future practitioners need the critical thinking tools and knowledge to clearly and dispassionately discuss why a given CAVM modality may not be the most ideal approach to a given problem. This can be done without creating the impression that CAVM is or should be an accepted part of scientific medicine.
1. If a client elects to proceed with a CAVM modality then it’s their decision, and though sometimes difficult, practitioners should strive to continue working with these clients if possible and promote what is in the animal’s best interests.
Tuesday, August 19, 2008
Many supporters of Complementary and Alternative Medicine (CAM) note that the low incidence of harm from these practices pale in comparison to the horrors of other human activities such as alcoholism, poor diets, religious dogma, and smoking. The general conclusion being that efforts should therefore be more focused on these problems rather than the more “benign” CAM medical practices- even if most seem to be ineffective modalities whose ‘actions’ fall within the realm of placebos (other posts will discuss the relative value of CAM -if any- and the context outside of medicine in which some of it’s services might be provided).
While these types of comparisons may seem to make sense- most of us want to address humanities problems in some way- we need to look a little deeper before we let the
The crucial issue here is that critical thinking has allowed for solid and palpable progress in many areas of human endeavor. The progress in modern medicine is due in large part to utilizing this skill to derive effective modalities from the realm of science- a discipline that has given us the closest picture of the true nature of things we have as of yet.
If you take into account the significant harm non-science based medical practices have wrought throughout history using combinations of ineffective and often harmful therapies, the importance of minimizing the bubbling cauldron of ignorance in medicine today becomes ever more urgent- even if these therapies “appear” harmless compared to demonstrably effective medicine.
Without the self critical, self correcting methodology of science, modern medicine stands to become another recent socio-cultural phenomenon- a postmodern paper tiger. Conflagrating consumer “choice” in medicine together with the gory details of humanities frailties, socio economic missteps, religiosity, and often schizophrenic behavior misses an important point. That is, where critical thinking has flourished; it has been possible to better navigate reality as it is.
Freedom of choice brings with it a huge responsibility; especially regarding others. Add to this the fact that freedom of choice in medicine is further tempered with society’s demanding expectation (for the most part) that it provide the most effective practice possible- no matter what a person “believes”.
To date science provides the clearest roads to this end. Unlike religion, politics, or cultural roots, science reflects universal realities (i.e., you breath oxygen, are structurally bipedal, and communicate using a complex recursive language). In kind, scientific medicine strives to derive knowledge and treatments based on these truths. Not a religion or cultural dogma, it can flex, bend, and change- based on expanding scientific understanding.
If medicines imposed science based limitations are removed, society will again be open to a plethora of competing false realities among which the placebo- that ghostly deception- reins supreme. Indeed, this type of medical “anarchy” silences the all important need for honest discourse. Instead of a place where human touch, emotional acknowledgment, and real communication can truly thrive- even under the harsh light of reality- a thick fog of magic, dogma, and ideological suggestion would smother any effective medical progress, and turn even simple human behavior against itself.
Monday, August 18, 2008
During the course of clinical practice, veterinarians (and physicians) often encounter a variety of circumstances that affect the daily course of administrating care to a patient. They can either be a hindrance or a help towards the goal of attaining the most appropriate medical treatment for a given individual.
For example, refusing a blood transfusion or declining blood work can greatly impede ones ability to treat or diagnose whereas people jumping in line to donate an organ opens the doors to previously impossible therapies. Such is the way of clinical practice as the doctor blends his or her experience, current available science based knowledge, and the patients (or owners) perspectives in order to come up with a “do-able” strategy. These approaches vary depending upon the balance between these spheres of influence and often translate into unique therapeutic approaches. The ultimate goal is to find an effective balance that is heavily tempered with the hammer of scientific methodology.
In other words, even though an elected therapy may vary in some way depending upon a given situation, it needs to “pass muster” so to speak. It needs to demonstrate a level of effectiveness, plausibility, and repeatability that results from steady and rigorous inquiry from a serious- admittedly imperfect- community of humans involved in an intense endeavor; the search for reality based solutions.
The alarms of reason and truth should be sounding all around the halls of higher education as these types of belief based and unreasonable systems gain a foothold within the realm of hard won legitimacy- without having any!
Dr RW discusses this very concern regarding the uncritical teaching of alternative therapies in US medical schools noting the alarming trend towards incorporating Complementary and Alternative Medicine (CAM) courses into their regular curricula. Are these courses being critically examined for plausibility and efficacy? The unfortunate answer is no! Sampson (University School of Medicine, California) cites in a 2001 study:
Another eye-opening reason to be concerned about the infiltration of uncritical thinking and associated CAM modalities into medical education is the example of the insidious growth of
Together, these observations reflect important warning signs the medical community needs to take seriously if the foundation of a reality based/critical thinking education is to continue to hold its proper role as the gateway to effective modern medicine.
Friday, August 15, 2008
The practice of Chiropractic medicine continues to be a controversial treatment modality in spite of persisting efforts by the Association of Chiropractic Colleges (ACC) to “integrate” into general science based mainstream medicine. One of the main problems is that the foundational theory and basis for chiropractic rests upon tenuous non science based concepts.The “Chiropractic Paradigm” proclaims on the ACC web site that the theory of the "subluxation", a nebulous entity not demonstrated to exist (let alone be the originating cause of a plethora of human and animal diseases) as integral to the practice of modern chiropractic:
"Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.
A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.
A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence."
In spite of efforts by more evidence based chiropractic practitioners such as Samuel Homola DC who strive to limit the extensive scope of unfounded treatment claims, a significant proportion of chiropractors continue to implement pseudo scientific methodologies.
One of the dilemmas for this profession is that a large part of its work involves spinal manipulative therapy (SMT) a separate practice often erroneously assumed to be only chiropractic in scope. In fact, physiatrists, orthopedists, sports medicine practitioners, physical therapists, athletic trainers all employ SMT in their practices. There seems to be some evidence that SMT relieves back pain to an extent and can be traced back to ancient history. Though this technique has beneficial qualities it does involve some components of the placebo such as the laying on of hands and perceived variations to pain.
Chiropractic differentiates itself from traditional SMT by prescribing to specific implausible theories such as the subluxation and that this entity is the root of nerves impingement's that lead to disease. Though the present chiropractic society strives to dress this concept with scientific legitimacy, the bottom line is that such theories have not met the criteria of quality research. Therefore, chiropractors who are working to reform the practice and limit its scope are faced with having to completely shift the “chiropractic paradigm” in a big way- a daunting task:
"The dilemma reformers face is that chiropractors do not perform any service or deal with any condition not covered by some other health profession. State laws that enable them to practice either specifically mention the subluxation theory or describe it as the basis for chiropractic as an entity. Renouncing chiropractic's theoretical basis would eliminate its justification for existing as a separate profession.
Reformers acknowledge that they offer mainly the specialized skill of SMT. They believe that SMT is underutilized and that a substantial market exists for their skills. Although other health professionals can legally perform SMT or treat functional back disorders, most do not. To become skilled at SMT requires more time and effort than most physicians or physical therapists are willing to invest, especially when they feel that they may achieve the same clinical results over the long term with less demanding modalities."
Chiropractic medicine has origins specifically from the strange metaphysical pondering of one layman; Daniel Palmer who speculated that most disease was caused by spinal subluxations that impinged nerves thereby leading to disease:
“Obsessed with uncovering "the primary cause of disease," Palmer theorized that "95 percent of all disease" was caused by spinal "subluxations" (partial dislocations) and the rest by "luxated bones elsewhere in the body." Palmer speculated that subluxations impinged upon spinal nerves, impeding their function, and that this led to disease. He taught that medical diagnosis was unnecessary, that one need only correct the subluxations to liberate the body's own natural healing forces. He disdained physicians for treating only symptoms, alleging that, in contrast, his system corrected the cause of disease.
Palmer did not employ the term subluxation in its medical sense, but with a metaphysical, pantheistic meaning. He believed that the subluxations interfered with the body's expression, of the "Universal Intelligence" (God), which Palmer dubbed the "Innate Intelligence." (soul, spirit, or spark of life).  Palmer's notion of having discovered a way to manipulate metaphysical life force is sometimes referred to as his "biotheology."
Human chiropractic today, under the cover and dressage of “science” still has not gone past many of these implausible notions. It is therefore easy to imagine why other peculiar modalities such as odd and implausible diagnostics (applied kinesiology, contact reflex analysis, “nutritional” consultations, reflexology, and hair analysis among others) have taken root in chiropractic medicine.
The relationship to spiritual world views of the soul at least suggests that expanding these concepts beyond the human body were not immediately considered. Animal chiropractic and animal souls seem not to have been an initial part of the theory for this treatment modality. The leap to animals however, did take place using a similar “intuition” and integrative approach used in other alternative practices (Note the resemblance to the “natural correspondence” theory and “energy” pattern and flow concept of the "qi" found in TCM).
The transposing of chiropractic to animals seems to have little basis in research and relies on the general precepts of the slippery “subluxation” theory. In addition to being an unproven entity in humans it is interesting to note that “No part of chiropractic education deals with animals, and no part of veterinary education deals with manipulative forms of physiotherapy.”
However, a veterinarian or chiropractor can be “certified” to practice animal chiropractic after complying with about 150 hours of coursework. These educational courses are offered at five locations approved by the American Veterinary Chiropractic Association. A quick scan of two of the websites indicates that the concept of the “subluxation” is alive and well in the arena of animal chiropractic:
"Integrated Case management " -6.5 hours – (All of the following are addressed by lecture, in small group discussion and/or with expert panel debate through an open question forum.) Review of the chiropractic theories and the contemporary vertebral subluxation complex; define assess and apply animal chiropractic diagnosis of the vertebral subluxation complex; and, investigate the creation and application of appropriate clinical goals and applying them to our integrative treatment protocols.”-
"What is animal chiropractic? "
Animal Chiropractic understands the relationship of the spine and nervous system to proper function and over all well-being of small and large animals. The application of this art utilizes a small amplitude, high velocity thrust to areas of spinal subluxation in order to facilitate proper function of the nervous system resulting in enhanced performance and quality of life".
The jump from one mans “epiphany” for curing disease through spinal manipulations is difficult to comprehend. The leap to animal chiropractic becomes even harder to grasp, especially if you consider the enormous variation in body types and sizes found in the animal kingdom.
Though animal based chiropractic education seems to address some anatomical topography, there continues to be a theoretical gap in the transition from human focused approaches to animal techniques. Additionally, the obvious fact that human body architecture is based on a bipedal mechanics and the vast majority of other animals are quadrupeds needs serious attention when considering practical and functional chiropractic transitions from human treatment theory to the rest of the animal kingdom.
Chiropractic medicine seems to continue to base its efficacy more on a priori knowledge, belief, testimonials, and pseudo scientific modalities rather than on scientific plausiblity and quality evidence based research. It is prudent to review some of the basic strategies the American Veterinary Medical Association has developed for veterinarians that are considering alternative modalities:
|"AVMA Guidelines for Complementary and Alternative Veterinary Medicine|
|(Approved by AVMA House of Delegates 2001; revised by the AVMA Executive Board April 2006)|
These guidelines are intended to help veterinarians make informed and judicious decisions regarding medical approaches known by several terms including "complementary," "alternative," and "integrative." Collectively, these approaches have been described as Complementary and Alternative Veterinary Medicine (CAVM). The AVMA recognizes the interest in and use of these modalities and is open to their consideration.
The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method. Circumstances commonly require that veterinarians extrapolate information when formulating a course of therapy. Veterinarians should exercise caution in such circumstances. Practices and philosophies that are ineffective or unsafe should be discarded."
This is is a call to veterinarians (and in essence, to all health providers) that we have a responsibility to provide effective and sound options to a public that entrusts us to find and offer them. Human and animal chiropractic medicine for the most part, has not met those standards.
www.chirobase.org/05RB/BCC?update.html (dated, though good assessmant )
Animal therapy over the ages2. chiropractic 3. homeopathy. Haas BK. Veterinary heritage. 1999 Nov; 22(2):38-42
Thursday, August 14, 2008
Today, veterinary acupuncturists of all types are literally every where. As human acupuncture practice has become more popular in the last 20 years, the consumer seems to have increasingly sought similar treatment for their pets. It is now common place to observe some type of alternative medicine, of which acupuncture seems quite common, being offered even in non-alternative oriented practices.
There is also seemingly no end to the maladies and conditions in animals that acupuncture can treat or support. These claims embrace many different animal species and include such diverse disease as equine colic (abdominal pain) and canine arthritis to reproductive and metabolic disorders.
One problem though, is the huge vacuum of any substantiated evidence (damned pesky word again) that might back these claims in animals ( including humans). There are recent acupuncture studies that claim positive results regarding, for example, points associated with metabolic mechanisms or 'epigenetic' effects. However, extreme care should be taken in interpreting these results until quality evaluations on them can be done.
Interestingly, there appears to be country based bias problems to overcome in addition to quality assessment when evaluating many of these studies. Overall, there is precious little in the way of well constructed studies in veterinary medicine or even in human medicine that take a good look at acupuncture effects, or for that matter, veterinary acupuncture technique. There are systematic reviews that conclude that the many studies that do exist involving domestic animals are of low quality and have equivocal results. Also, the higher quality studies out there point to more negative results with regard to the efficacy of acupuncture.
The point is….where?
One of the more salient details in animal acupuncture though is the problem of acupuncture meridians and points. How were animal meridian charts developed? Veterinary acupuncture seems to be a much more recent phenomenon than assumed by many of its practitioners.
This opens up a hopeless quagmire of contradictions between present day acupuncture and the historical acupuncture record. Chinese historians of human acupunture describe ancient acupuncture as manipulating qi (vapors) running through mai (conduits) by puncturing the skin with needles. The first theories regarding what developed into human acupuncture are described in the Huang Di nejing (Inner Classic of Huang Di) between the 5th and 8th centuries. This work introduced the idea that the human body contains "depots" connected by a series of conduits that allowed for qi to flow. Revealingly, there is no mention of similar theories concerning animals.
The oldest veterinary therapeutic description of anything close to needling can be found in Song times during or well after 1000 AD. Sources such as the Famma zuan yanfang (Compendium of Efficacious Recipes from the Nomadic Tradition) described needling in regards to cauterization and blood letting similar to what was practiced in Western historical medicine. Later in the 17th century the Yuan Heng Liaoma ji (Collection for Treating the Horse; circa 1608), an important veterinary text, described needle points in relation to bleeding, cautery, surgery, or divination...but not acupuncture. Additionally, it indicates -whatever the type of needling used- that human and animal treatment points were not the same. In any case, these ancient texts bear little resemblance to the type of veterinary acupuncture practiced today.
“Modern” veterinary acupuncture history utilizing meridian and point concepts can actually be traced, in large part, to 19th century Europe. The association of the historical vital vapor qi as being a form of energy was not made until 1939 which was when the term meridian was created (in human acupuncture as well). Interestingly, animal acupuncture meridians dates only to the 1970’s and were invented for Western practitioners. At this point, it was Western authors, for the most part, that formulated the various meridian charts for a variety of domestic animals by transposing human meridian charts to each animal species.
That the whole idea of acupuncture and "vitalism" oriented meridians can be transposed from humans to any species is one of many modern “intuition” oriented discoveries that gave form to today’s veterinary acupuncture. The actual historical record contradicts the common "appeals to ancient knowledge" often associated with acupuncture. It seems that modern veterinary acupuncture utilizes recently formulated meridian charts that were basically made up. In essence there is no real point… to put the point.
Historical reference: Complementary and Alternative Veterinary Medicine Considered, Ramey D, Rollin.B
Wednesday, August 13, 2008
The last decade has seen a veritable explosion of animal nutritional products of all kinds as innumerable food and supplement companies ply their wares to a largely eager public. A simple stroll through many pet stores illustrates this fact as evidenced by the quantity of options readily available to a consumer already accustomed to variety and choice.
There is an endless array of different colored and sized bags ranging from economy priced to “designer” categories of foods featuring premium grade ingredients. There is no end to the list of “special” additives such as nutraceuticals, herbs, and anti oxidants featured on many pet food bags claiming improved joint function, shinier hair coat, or increased intelligence. There are a variety of general movements within the mainstream pet food industry as well as along its margins that promote specific diets such as the “archetypal” dog food or raw food diets . There are even companies that enthusiastically support the concept of breed specific and gender based diets .
This is only the tip of the ice berg where the world has seemingly gone mad churning out a mind boggling array of all types of nutritional supplements, vitamin mixtures, herbal concoctions that include liquids, powders, pills, or capsules. There is sensory overload of images that can blunt any rational consideration of what to buy.
Through the years, there were occasions along the way when I got caught up in the latest furor regarding a nutritional concept or whole heartedly supported a fictional or unsubstantiated food paradigm because "it made sense". I was sometimes swept away by attractive jargon or beautiful ideas that later proved far too simplistic. This experience has helped me sort out that the basics; moderation and balance are the keys to solid nutrition. I know-boring, but true!
Michael Shermer in “Why People Believe Weird Things" describes his experience with alternative nutritional and medical practices during his career as a cyclist. With the attitude “it can’t hurt and maybe it will help” Mr Shermer experimented with a plethora of strange medical practices such as colonic therapy, metabolic supplementation, and a form of live blood cell analysis to mention a few. Realizing over time that these approaches had no obvious effect and sometimes even seemed to have a negative impact, he eventually became deeply skeptical. Hence his fascination as to why do even smart people support dubious and questionable practices?
Its a no brainer many very intelligent people readily get caught up in odd concepts and fuzzy intellectual ideas. Without the right tools to probe the reality of ones surroundings it is extremely easy to stray. Add to this the confounding factors of human emotion and ego and it becomes a wonder we can ever get things even close to how they really are!
What does this have to do with nutrition? By creating a set of basic foundational concepts, whether they are based on fact or not, one can create a skewed view of reality and construct vast, complex worlds that may have a tenuous hold on the truth and little to do with the way things actually are. By making false assumptions or establishing weak relations as fact it is not difficult to explain any idea. The hard part is deconstructing a false model one has worked so hard to put together, especially if it becomes deeply ingrained in your psyche or begins to mesh intimately with your beliefs.
This is the genesis of extraordinary paradigms and, on the surface, apparently solid ideas. In the case of religiosity, they might be survival mechanisms, they might be by-products or something else. In nutrition these paradigms are clearly delusional and can be described as “Paranormal” constructs of nutrition.
If these “Paranormal” nutritional concepts are expanded upon and sprinkled with half truths and occasional facts, the "big picture" of animal and human nutrition can become just a pretty mirage. Add to this the alluring siren call of major monetary income and you have a hell of a mess.
If one looks over the panorama of food and supplement companies in this country (
The many tenants and facts permeating "paranormal" nutrition are based more on belief and opinion than reality. After coming across too many contradictions and unsupported facts, as a one time "believer", I finally humbly returned to being a cautious “hopeful” skeptic.
Many nutritional ideas might have a solid factual basis and convey intriguing possibilities in preventing or improving disease. Generally though, proponents tend to jump the gun, often skipping fundamental limitations, while highlighting convenient facts over contradictory ones to reach tenuous conclusions.
In coming posts, I will touch on specific examples of how nutritional ideas can take unusual paths and discuss how some food and supplement companies bypass label claim limitations using "nutritional seminars", alternative medicine providers, and even science based veterinarians and physicians.