Should Complementary and Alternative (aka Integrative) Veterinary Medicine be taught in vet schools?

The short answer is NO.

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.

CAM and higher education

A tragedy in the making?
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.

This has been the responsibility society has given to the medical community, especially in the last century. Though the nature of healing may have a seemingly infinite set of variable influences and built in uncertainties, it has been wisely placed under the guiding light of methodologies that allows for consistent and tangible results.

Herein lays the growing concern when faced with a set of practices that walk away from these hard won lessons regarding healing. Though science is not a cult, religion, or some particular “post-modern” version of reality there are those who think that it is one or all of these things. Due either to misunderstandings, misrepresentations, and mostly, a lack of adequate science education many people falsely compare the hard won knowledge of modern medicine equally with archaic and implausible modalities such as homeopathy, the five elements, and most of chiropractic theory.

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:

"Advocacy and non-critical assessment are the approaches currently taken by most U.S. medical schools in their courses covering what is commonly called "complementary and alternative medicine" (CAM). CAM therapies are anomalous practices for which claims of efficacy are either unproved or disproved. The author's research indicates that most medical schools do not present CAM material in a form that encourages critiques and analyses of these claims. He presents the reasons for the unwarranted acceptance of CAM. These include the CAM movement's attempt to alter standards of evaluating therapies. A survey of CAM curricula in U.S. medical schools in 1995-1997 showed that of 56 course offerings related to CAM, only four were oriented to criticism. The author's course at Stanford University School of Medicine approaches CAM with the skepticism and critical thinking appropriate for unproven therapies. The author concludes by calling on all medical schools to include in their curricula methods to analyze and assess critically the content validity of CAM claims.”

Another recent 2007 survey reviewing preclinical students at Georgetown University School of Medicine reflects a possible receptivity to CAM and illustrates that science based education and critical thinking skills may be lacking in earlier formal education:

“Interest in and enthusiasm about CAM modalities was high in this sample; personal experience was much less prevalent. Students were in favor of CAM training in the curriculum to the extent that they could provide advice to patients; the largest proportions of the sample planned to endorse, refer patients for, or provide 8 of the 15 modalities surveyed in their future practice.”

This 2002 survey explored the apparent lack of familiarity in US medical schools of CAM and the disconcerting assumption that these modalities are effective therapies:

“A wide variety of topics are being taught in U.S. medical schools under the umbrella of CAM. For the most part, the instruction appears to be founded on the assumption that unconventional therapies are effective, but little scientific evidence is offered. This approach is questionable, especially since mainstream medicine owes much of its success to a foundation of established scientific principles.”

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 CAM in the nursing profession as described by Sandy Szwarc.

“…it is also important that the public understand what is happening and that we hear the voices of nurses who are concerned about the growing adoption into nursing practice of alternative modalities that have no scientifically valid theoretical underpinnings or proven medical efficacy.”

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.