7 minute read
The Integrative Umbrella
More clients are asking for CAVM, but how do we respond when we don’t have ideal scientific evidence to back up these therapies? Here are the tools to weather this dichotomy.
by Richard E. Palmquist, DVM, Past President AHVMA, Co-Diretor AHVMA Foundation
Veterinary medicine is a massive endeavor. Veterinarians are collectively responsible for all knowledge that could be used to maintain or rebuild health, or to relieve suffering and improve quality of life for the animals placed in our care. Since the knowledge and data used to treat our patients and perform our duties as veterinarians is incomplete, we are often asked to address situations that are, to say the least, unique. As professional students at Colorado State University, we were taught that the material we learned would be outdated quickly and that we must learn to find and assess data if we intended to be the best clinicians possible. No truer words were ever spoken.
The Best Approach
Complementary and alternative veterinary medicine (CAVM) relates to tools that are rapidly expanding in their use in our profession. Since many veterinarians are not trained in these techniques, they find it hard to understand how they might be useful, and since research in CAVM is not funded in amounts proportional to other realms of veterinary medicine, it is not surprising that there is some confusion about how to best approach this subject.
Groups like the AHVMA Foundation are working to improve these deficiencies. On a broad, national basis, the AVMA guiding policy on CAVM states: “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” (AVMA Guidelines 2007).
Veterinarians from the heights of professional academia to the trenches of clinical practice are generally in agreement with this sentiment. In a 2011 survey, deans of veterinary schools agreed that “CAVM is an important topic that should be addressed in veterinary medical education, but opinions varied as to the appropriate framework” (Memon, Sprunger).
Many veterinary schools in that survey offer courses and laboratories involving CAVM, and all agreed that such education should be carried out within an evidence-based medicine environment. One school requires a course in CAVM to graduate. Veterinary schools are expanding their trained faculty and ability to better understand CAVM modalities, and this is a good thing because public demand for CAVM is rising at an ever increasing rate. In the recent economic downturn, practices offering CAVM and integrative medicine reported having steady demand while many other practices shrank.
The umbrella analogy
Fundamentally, all veterinarians are seeking tools they can reliably use to assist them in their mission to improve animal health. The entire field of human and veterinary medicine could be envisioned as a large umbrella, which when properly used assists and protects those using it. We all know about umbrellas. They are one of those simple tools we often take for granted, but if we study the umbrella, we gain some insight into veterinary medicine as well.
A tool requires a user. Someone must wield the tool. This requires good judgment both in the use of the tool as well as in its selection. In the hands of a person with good judgment, a tool is far more useful and far safer. The user can also abuse a tool if she lacks good judgment. This can cause others to have a bad opinion of the tool, when in fact it was the user’s abuse of that tool that led to poor outcomes.
A tool requires training and experience in its maintenance, care and use (Tan, et al 2011). Training and practice are required to properly use any tool we select in our profession. The better the tool is researched, the better the knowledge we have for its use. And knowledge of proper use coupled with good judgment allows us to use our tools with the greatest success. Training reduces a b u s e , w h i c h i s a w o r d t h a t a c t u a l l y m e a n s “against its purpose, or improper use”. Properly balancing intuition and training is necessary for optimal success (Balla, et al 2009).
A tool requires that all parts be functioning properly for its proper use. If we consider our medical umbrella to have various parts, then we can see that the use of an incomplete umbrella might lead to some discontent or disagreement. Each portion of the body of the umbrella could symbolize a particular portion of medical knowledge: anatomy, physiology, pharmacology, surgery, biochemistry, epigenetics, genetics, physics, acupuncture, chiropractic, herbal medicines, neurology, cardiology, dermatology, gerontology, oncology, etc. In this analogy, we can easily predict that a clinician given an incomplete umbrella would be less than satisfied. He or she would actively seek to find, replace, redesign or otherwise improve the incomplete umbrella. While holding the incomplete umbrella, some users would feel that something was not right and would strive to improve their tools, while others would possibly feel this was just the way things are and be happy with the status quo.
Outside the box
As veterinary clinicians, we regularly apply knowledge across species without ideal evidence, and we try new things when other therapies are failing (Toews 2011). Ethically, we promise to use our tools for the best outcomes of our patients, and we strive to reduce suffering and improve quality of life. We use amoxicillin in cats even though the FDA approved label states “for dogs only”. We give subcutaneous fluids to renal failure cats even though no clinical trials exist for the procedure. We use acupuncture to reduce suffering even though it was unheard of in this country prior to 1960. A friend of mine, Dr Barbara Royal, successfully treated a zebra and several camels in Chicago zoos with acupuncture. There certainly were not any clinical trials available for her reference, but she responded to the call for help and used her intuition and clinical expertise to assist a species she was never trained to treat (Royal 2012).
It is not possible to create evidence-based professional tools that cover all cases at all times and base these on established information, because that information infrastructure simply is not available (Murphy 2003). That is part of the excitement of being a veterinarian, as we take new tools, apply them in unique ways, and share them with others interested in reducing suffering and improving outcomes.
A tool can be used in less than optimal conditions, but under periods of stress or duress it can fail the user. In that moment, the user can become upset and demand change. Some users will blame the tool and simply throw it away, while others will find the weakness and realize the rest of the umbrella is still needed. Burnout is an important issue arising from such challenges (Shanafelt, Dyrbye 2012).
If we can just add to the missing parts, then things improve and move forward. Research is the handle of our umbrella. Without proper research, we cannot identify and properly include all the parts needed for the umbrella to be fully functional. Research supports and gives strength to the umbrella of medicine, so that those with good judgment can properly use the tool. Without research and validation, the entire tool will fold up in bad weather. As we begin to evolve into translational medicine in the veterinary profession, we will find this process accelerates. It is possible to pioneer areas, develop interdisciplinary evidence by integrating known data, and validate it for more rapid and proper patient care (van den Hoonaard 2009; Burgio 2010; Moore, et al 2011). The truly exciting fact is that as we approach a “one health” or “one world” form of integrated health care for humans and animals, the importance of research in all areas of science will expand exponentially (Zinsstag, et al 2011).
We would question someone who would use their other tools to destroy the entire umbrella, or who would prevent others from attempting to make it more functional. Likewise, we would admire those who work to maintain the umbrella’s strength and usefulness. The integrative veterinary medical movement is simply taking areas of CAVM and cooperatively applying properly done research until those parts can be identified and included in the protective parts of the umbrella (Sackett 1997). It is a very organic process that begins with an interest in helping others, proceeds to an investigation of its components, and ends with the addition of knowledge that assists your activities. This gives all veterinarians better tools to withstand the storms of clinical practice, while maintaining advancement of those fields through the generally accepted evidence-based veterinary medical model.
