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VetInfo Digest May 2004

Table of Contents:
Information Sources
Is it Science?
Practice Philosophies
E-mail is still having some problems.

This Month's Note:
People ask me pretty frequently why I have never written a book, or at least taken some of the information from the web site and VetInfo Digests and compiled it into book form. There are several reasons for this but the overwhelming one is that medical information changes fast enough that I know I would be dissatisfied with the information contained in the book fairly quickly. The solution to this problem on the web site has simply been to date entries so that people can see the most recent one and to update as new questions were answered. This process has slowed a little since we stopped stating that we would answer all questions online but it still goes on enough to make me comfortable.
I have been a member of a committee to help choose local students to attend the Governor's school for several years and each year I ask the students to define "science". To be honest, no student has really been able to come up with a comprehensive answer, yet. This year, as I thought about what to ask students, it occurred to me that I had never really tried to come up with a concise answer to that question, either. As I thought this through and wrote down my thoughts, it suddenly occurred to me that few people really understand the thought processes that veterinarians go through in making decisions on a day to day basis. So I thought that I would try to put down a little of this information in one or two issues of the VetInfo Digest and if that worked out well to rethink writing a book about it. The basic thought process necessary to succeed in veterinary medicine doesn't change all that frequently and perhaps this might be a worthwhile project.

Information Sources
One of the biggest problems for veterinarians is figuring out how to help clients understand how to sort through all the information available on pet health care and effectively evaluate what they find.
This was much less of a problem in the past because veterinary information was more difficult to obtain. When I graduated from veterinary school twenty-five years ago most clients recognized that the information that I had obtained in veterinary school and through veterinary texts and journals was different than the information they could obtain from their neighbors, news sources and pet or family magazines. At that time veterinary texts were five or six times as expensive as New York Times bestsellers and most clients had no idea how to obtain the texts even if they wanted them. Many of the veterinary publications refused to allow non-veterinarians to subscribe (some still do). There was no public access to the Internet and libraries were not as good at sharing information among themselves as they are now. Television commercials touting pet health care products, especially those with some amount of educational information, were rare. In short, veterinarians at that time did have access to more and better information than most pet owners.
It is easy for a veterinary client today to research a particular disease or disorder in depth using a combination of resources that has become available over the last few years. Pet health care books have improved, with several references containing information that is gleaned from a number of experts. Magazines devoted to pets often contain in-depth articles on veterinary topics. This information is sometimes difficult to objectively evaluate but it is often accurate and sometimes even "cutting edge". Libraries will often search for and obtain reference material for their patrons. The Internet has cut out the textbook middleman and allows veterinary researchers, veterinary practitioners and non-veterinary health care providers or sources to provide information directly to anyone with a computer, a phone-line and interest in researching pet health care topics.
Veterinarians feel pressured by this assault on their territory. Some vets almost reflexively disparage information that comes from any source other than themselves. Other vets do spend a great deal of time trying to help their clients understand information they have copied from the Internet, heard from their pet's groomer or obtained at breed conventions or through other sources. At times this is costly for the veterinarian, who really does depend entirely on selling his or her time to make a living and rarely can charge for time spent consulting with a client about information the client has discovered. On the other hand, motivated clients are often the best veterinary clients and so it is a situation in which there may be long term gains for a veterinarian willing to spend some time helping clients understand information.

Knowing the background that most veterinarians come from and looking at some examples of how veterinarians evaluate information may help you to do a better job of evaluating pet care information yourself and may also make it a little easier to approach your vet with information that you really need to discuss in order to understand your pet's care or to ensure that your pet receives the best possible care.
The first thing to keep in mind is that most veterinarians have a very strong science background and tend to evaluate information with a scientific mindset. The preveterinary curriculum includes courses in chemistry, biology, zoology and physics. This curriculum isn't really designed to make veterinarians scientists but it is designed to teach them to think about information from a scientific viewpoint. Since many veterinary clients have much less training in the scientific method it seems best to review what this really means.
The scientific process involves collecting information, evaluating that information and coming up with an hypothesis to explain its meaning, testing that hypothesis in a manner that keeps other factors from interfering with the testing and then evaluating the test results carefully to see if the testing confirms the hypothesis. One of the most important parts of this process is being willing to modify or abandon the hypothesis if the testing doesn't confirm it. The word "science" is thrown about haphazardly by a lot of people who are trying to sell products or services and in many articles about pet health care in general. I'm almost certain that the false claims of scientific validity exceed the amount of information that truly has a scientific basis, at least when it comes to pet health care issues.
Surprisingly, though, a great deal of the information that most people, and even most veterinarians, feel has a scientific basis really doesn't. It is almost frightening how frequently I review the scientific basis of information that is available in textbooks or from other sources only to find out that it really has not met the basic requirements to be considered scientifically valid.

Is It Science?
Many veterinary clients don't have much training in evaluating scientific information, so I need to spend a little time here discussing the methods of determining if information really is valid.
The first thing to think about when considering scientific information is easy. Does it sound like it could be true?
This week I had a client come to my office and tell me that she was thinking about switching dog foods to one that her groomer sells because the groomer made a very convincing case that all the chemicals in dog food were causing illnesses and cutting short the life span of dogs. She said that her groomer told her dogs should be living 25 to 30 years, just like they used to. So the first question I asked her was whether she knew of a time when dogs lived that long. This particular client just said "no". I have had other clients who have told me that the groomer was referring to dogs in the wild. This almost makes me laugh out loud when people say it but I usually try not to. Wild canines are lucky if they live two or three years. There is no evidence that wild dogs ever lived for thirty years. I am not aware of any time in the past when it can be demonstrated that dogs lived longer than they do now. Based on my time in veterinary medicine dogs are living slightly longer now than they did when I started in practice and cats are living significantly longer. My best guess on cats is that it doesn't have much to do with diet but more to do with cats becoming pets worthy of care. I rarely hear "it's just a cat" in my practice anymore as an excuse not to spend money for a necessary treatment. The claim that pets used to live until they were thirty is almost certainly untrue and an indication that the information may not merit exploration.
The other claim, though, is a lot harder to evaluate. Is it possible that food components or chemicals such as preservatives are causing chronic illnesses or shortening the potential life span for pets? This at least has some potential for being true. So how is this sort of claim to be evaluated? The first thing I would do is ask the groomer for some proof of the claim. If she can not provide it but insists that the dog food company can, then I would write to the dog food company and ask for the proof. Then look at the "proof" and check on the validity of the sources, read any articles cited and think about this new information in the same vein as the original information -- does it sound true? While this is just an aside, I once was involved in a fairly intense controversy with a small specialty dog food company when I was director of the Pet Care Forum on America Online. When I pushed hard for proof of a company's claims before allowing them to post them on the forum's message boards the answer I got back was a two word reply with the second word being "you". That was enough to convince me that the pet food company's claims were suspect.
On the other hand, I spent a great deal of time over the course of a year or so researching and attempting to evaluate the effects of ethoxyquin, a preservative, which is used in dog food. Despite a pretty diligent effort, including obtaining a box full of information from Monsanto, the preservative's manufacturer, I was not able to come to a firm conclusion about its safety or lack of safety. The best that I could say after all that time is that for most dogs the preservative seems to have little or no effect but it did look like it might have been involved in problems experienced by a few dogs. There were no studies on either side that were really solid enough to depend on them entirely, although it was pretty clear that most dogs will not experience health problems if fed a dog food with ethoxyquin in it.
Most veterinary clients are not familiar with interpreting articles in veterinary journals but when a serious health problem occurs in their pets some people will find that they have to go to these sources to truly understand the nature of the problem or to ensure that their pet is receiving the best care. It can help a great deal to have a medical dictionary handy if you do decide to search articles on line or in journals. We use Bailliere's Comprehensive Veterinary Dictionary (Blood and Studdert) pretty frequently but a human medical dictionary will work most of the time.
Several things are necessary to consider when evaluating information in scientific studies ( or journal references) concerning medical care:
1) Was the research group or clinical trial size large enough to be scientifically valid?
Surprisingly small numbers of patients can be considered to be statistically valid. In general, studies involving more patients give better results than studies involving small numbers of patients.
2) Was the information collected in a manner that was likely to ensure that it was unbiased?
A key factor here is checking who paid for the research study and/or the employment status of the person writing the article. It is certainly possible for an employee of a pharmaceutical company to write a fair and balanced review of a product made by that company. Unfortunately there is also a tendency to design studies that support company products or to evaluate information in the most favorable manner when writing for one's employer or the supplier of your study grant. Truly independent studies are better. Other sources of bias can be harder to detect, such as a researcher who is still trying to defend a claim that has been questioned by others. As you check on information be careful to look for any source of bias.
3)Was there a double blind study?
In clinical trials the best studies are referred to as "double blind" studies. In these studies neither the veterinary client nor the veterinarian is aware of which patients receive the actual treatment and which ones receive a placebo or sham therapy. Patients should be matched up well enough that the group receiving the placebo is an actual control group, which is a group that shows what happens to similar patients not receiving therapy. Obviously, there are many situations in which it isn't possible to do double blind studies (surgery is one such situation).
4)Was there a control group?
The second best studies are ones in which a treatment is used and a control group is maintained that doesn't receive treatment and which matches closely with the group receiving treatment. If there is a significant difference in how the two groups fare this can be used as proof that the treatment works. It is critically important to understand what the researcher considered to be a significant difference, though. If a medication provides a 10% increase in survival rate that would normally be considered significant -- but it may not be enough to make the treatment worth considering it if causes other effects or is extremely expensive. Studies without a control group should always be suspect. That doesn't mean the information is necessarily invalid, it means that you just have to be more careful about accepting it.
6) Is the study repeatable and has it been repeated?
It is best if studies have been repeated by more than one researcher or research group and the findings match. Even with great care it is possible to have flawed data in a single study, especially studies involving small numbers of subjects.
7) Was the information published in a refereed journal?
This has good and bad sides to it. The good side is that a refereed journal is one in which information is reviewed for scientific accuracy and study technique before being published. This is usually a good thing but at times it leads to the suppression of information that actually is valid but deviates widely from the current "mainstream" thinking. It sometimes becomes a political process in this case. Additionally, the original concept of refereed journals was to have a panel of experts review information but the practicality is that often a single reviewer is used and if that reviewer has personal biases against the information presented it may mean it doesn't get published.
8) Are any statistics in the article valid?
This can be a hard question for someone with no training in statistical analysis to determine but at least take the time to look at the numbers to see if they appear to support the conclusions drawn. Try to figure out what the researcher considered "success" to be. If a chemotherapy drug helps a patient live five days longer on the average it may be touted as having statistically significant effect on therapy for the cancer -- but is that success in your mind?
9) Did the researchers draw the right conclusion?
This is something that I think is critically important and that creates a major flaw when research is done using Internet searches. For those of you who may not be familiar with finding journal articles through sources like PubMed (http://www.ncbi.nlm.nih.gov/PubMed ), most of these sources present journal abstracts. These are short synopses of the articles, often written by the author. If the author's conclusions weren't supported by the study data it is much harder to tell that from an abstract. You must be extremely careful when drawing conclusions from abstracts of journal references or reviews of those references. It is possible to do so, order the entire article when its meaning may be critical to your pet's care.
10) Are references used to make the original hypothesis or to help validate the conclusions given?
If so it is often extremely helpful to search for and find the listed references. The Internet is a great aid in this search, as it is possible to type in the author's last name and initials, such as "Richards ME" into the PubMed search engine to find the listed reference. There are lots of journals that are not included in the PubMed database but it is a good starting point.
There are going to be many situations in which you aren't going to be able to locate recent references or sometimes any references to support or refute a claim that you have heard. In this situation you have to have a different set of rules to think about. These are meant to help you think about where information comes from and what it might mean when you really just have to go with your gut opinion.
1) Is the person you are receiving information from likely to be the best source of this particular information?
I am constantly amazed by some of the sources of information that my veterinary clients appear to consider as valid, or even more valid, than information that comes from me. If a pet store employee is making medical claims about dog food or pet health care products is that information more or less likely to be true than information coming from your veterinarian? In general, I hope that you chose "less likely" as your answer. If not, you should carefully consider changing veterinarians. If it is your neighbor giving you the information, is it more likely or less likely to be true than your information from your veterinarian? Again, I hope that you answer "less likely".
Even though I think that you have to think about the source of information I also think that you have to be realistic in evaluating the information regardless of the source. Veterinarians sometimes give out incorrect information. In the case of veterinarians you have to strongly consider question number 2:
2) Is the person trying to sell you something?
People who want to sell you a product often exaggerate or lie about the value of the product. I suspect that this doesn't come as a surprise to you. Unfortunately, veterinarians are susceptible to believing claims from people who sell them products and passing on those claims without checking them out. In addition, veterinarians are in business and some veterinarians value the business aspect of their practices more highly than they value the medical aspect of their practices. I honestly believe that most veterinarians do try to be a good source of information and that most put their patient's needs (or their client's needs -- more about that later) first. Despite this, you have to maintain some level of suspicion about information when the person giving it will profit from it.
Veterinarians have an obligation to check out information very carefully that comes from veterinary pharmaceutical companies, distributors of veterinary products and other sources that are not as reliable as other information sources such as journal references or textbooks. I can have two or three drug reps in my office in one day, all of them claiming that their product is the best and safest product for pain relief or the best vaccine against a particular disease. Only once in my entire career can I remember a drug company representative looking me in the eye and saying, "This is just a me too, product, Doc. Our company had to produce something to compete in this market but our product isn't any better than any other one."
3) Is this brand new information or a brand new product? It is often a lot better to wait a little while and see how a product actually performs in the marketplace before using it. Veterinary medical products are often tested in small groups of animals and rare side effects may not be noted until the product is used in large numbers of pets. Most really serious side effects surface within a year or so of the introduction of new medications. There are exceptions. It took almost ten years for the link to cancer between killed virus rabies vaccinations and feline leukemia vaccinations to surface. Unless use of a new medication is urgent, you might want to consider letting other people try it out with their pets before you try it out with yours.
New information concerning diseases that are hard to treat and less expensive ways to treat common conditions spreads incredibly rapidly at times. So rapidly that this information is often reported incorrectly or purported to be more carefully studied than it really is. Be careful about believing information that seems to contradict conventional wisdom.
4) Why does the person believe the information they are relating to you? To me, this is often the most telling question that you can ask. In the case of veterinarians it sometimes gives me a great deal of insight into the way they think about information which may have a big impact on whether I believe it.
There are four really broad categories of thought among veterinarians when it comes to their methods of evaluating information.
a) "This is what I was taught in veterinary school." This is the answer that I hate to hear from any vet who has been out of school more than a year or so. By the time a veterinarian graduates from veterinary school some of the information they learned in school is out of date. If they never review any information critically after they graduate but just stick with what they were taught, their education becomes almost worthless within ten years or so. By that time they are just doing the things that are routine from day to day and ignoring or missing everything that has changed. Very few veterinarians really stop learning after they graduate from veterinary school but a few do. If you ask your vet questions about why things are done the way they are and you get the answer "Because that's what I was taught in veterinary school" every single time, you might want to check to see if there is newer information.
b) Evidence based medicine is a philosophy in which information is evaluated based on the evidence to support it or refute it. Ideally it would be possible to find scientifically valid information on every aspect of veterinary care but the reality is that a great many of the procedures and even the medications used in veterinary medicine have not been rigorously tested. Over time this situation should improve but it is likely that there will always be some aspects of veterinary medicine that are simply too difficult or expensive to test adequately.
c) Faith based medicine is the process of picking a medical philosophy and sticking with it regardless of the evidence for or against it. Some people think that faith based medicine only refers to things like homeopathy or traditional Chinese herbal medicine, in which it is necessary to accept an underlying philosophy that is difficult to prove scientifically. I think that believing in the type of medicine typically referred to as "conventional" or "Western" medicine so strongly that new medications and new concepts are accepted blindly is just as strong an example of faith medicine. Where it is possible to prove that a medication works it shouldn't matter what the underlying philosophy of the person who developed the treatment was. Where there is no proof, all veterinarians engage in some form of faith based medicine.
d) "In my experience"
I have to admit that I use this expression pretty often and it worries me almost every time, but since it isn't always possible to find good scientific evidence, it has to do. The problem with clinical experience is that it is very variable and that relating cause to effect in medicine has been proven to be difficult over and over again when looking back in hindsight after good scientific studies have been done.
These are some examples of "in my experience" problems that might help you to understand the dilemma associated with this practice philosophy:
The first 85 dogs (approximately) that I treated for parvovirus lived, despite published figures attesting to a 20% death rate in parvovirus even with effective therapy. I thought I was a parvovirus genius by about the 50th survivor. I had full confidence that I had found the only way to treat parvovirus by about the 80th dog. I was getting ready to write a paper on how to treat parvovirus. Then the next 25 dogs in a row died. Even though statistically I was now right in with the rest of the pack, I really started to doubt whether I could ever get another patient through parvovirus by about the 10th death and was really getting desperate to find another treatment method by the 20th death. If I had tried something new at that point and it had worked, I think I would have believed in it forever. Over time the parvovirus cases took on a more normal distribution in our practice and we would lose a puppy every now and then but not in streaks. I was neither a parvovirus genius or an incompetent vet, I just hadn't treated enough cases to find out that I was no better or worse than the average vet treating parvovirus.
I know several veterinarians who do not do surgery at all. Almost all of them made this decision based on the first two or three (or even one) surgery they performed. Surgery is a very scary procedure for many vets because the outcome is often clear -- it worked or it didn't, the patient is alive, or the patient is dead. When the first surgical procedure that a vet performs goes badly, even through no fault of their own, they question their ability, they question the need for surgery and they often simply decide it is beyond their capabilities. Not too many medical procedures are quite as clear cut in their outcomes as surgery and strongly risk adverse veterinarians tend to lean towards medical care over surgical care. Still, if their early clinical experiences had gone better it seems likely that they might have a different opinion of surgery and their patients might receive more balanced care.
In reality, most veterinarians practice a mix of all four types of medicine. Even after twenty-five years in practice I occasionally stop and think about a procedure and realize that the main reason I do it the way I do is because I learned the technique in veterinary school and it has worked well enough that I have never sought information on new ways to do things. On the other hand, when there has been enough proof that a new way of doing something is safer or more effective we have been willing to make changes in hopes of improving our patient's lives. Over the years I have come to trust the work of certain veterinarians and I do sometimes accept what they say without any further examination, a definite statement of the faith I have in their work. This has worked out well for me, as it is not possible to research everything, but it is still a form of faith based medicine.
Clients are sometimes more complex in their approach to medicine than most vets, probably because they lack a common educational background like veterinarians have. Our clients tend to mix and match medical philosophies readily and to believe in a wider number of medical information sources than vets.
Some of my clients reject science completely. They tell me that scientific information has changed so much during their lifetimes that they see no value in it at all or they have rejected it for religious or other reasons. This is frustrating to me as a veterinary practitioner because there isn't much question in my mind that applying the scientific process to medicine is the best way to differentiate really effective treatments from ineffective therapies. If the person that you are getting information from can't or won't provide scientifically valid information you have to start with the assumption that the endorsement is based on faith alone.
While I am worried about the long term consequences of simply rejecting science , this may be no worse than simply refusing to evaluate scientific claims because it is too much work. It is really surprising to me how many clients are perfectly willing to believe claims of "scientific studies" or "scientific examination" without even bothering to find out if there really is anything resembling scientific thought behind an idea or a new medication advertising that "science" proves it works. Often it only takes a few minutes to check on these claims, especially when they are clearly false or misleading. If you do get references to a scientific study don't assume that it is valid, check it out for yourself.
If you are getting information from someone that seems to run counter to what your veterinarian is saying and the person says they got the information from their vet, don't assume that it is true. It is astounding how often clients come to the office and relate incorrect information on a product's use or dosage and tell my staff they got the information from me. I have had a couple of conversations with clients in which they told me I told them something that was clearly wrong and which I am virtually certain I would never say. One recent example was a person who came to the office and said that I told them they could give their cat Tylenol. Since acetaminophen is toxic to cats at any dose, I'm virtually certain I didn't say that. If it seems important to check on the information ask for the veterinarian's name and call their office to see if the information is being related correctly. Most veterinarians are happy to correct any misperceptions about what they have said and most willing to pass on information that might be helpful to another vet, as well.
Don't believe television and magazine advertisements. There is no guarantee of truth in advertising. The marketing departments of pharmaceutical companies appear to be experts at "spin" -- the art of making their products look better than they really are. A claim in an advertisement should simply be viewed as a starting point in your information search on the product. When you hear yourself saying "yeah, but it would be so nice if that really was true....", that's the time to really do some research.

These things are starting points when you are thinking about all the information that you receive on a daily basis. Next month I hope to go into more detail on how veterinarians actually make decisions on a day to day basis. Knowing the basic information sources available and how to interpret them is helpful and if you recognize the basic philosophy your vet works by it can help you decide where you need to fill in the gaps in information acquisition. Unfortunately, it doesn't quite make it possible for you to understand why vets take the same information and sometimes come to completely different opinions on the cause of a particular pet's problems. Hopefully I'll be able to clear that up a little next month.

Ongoing Network and E-mail Problems
Please let us know if you fail to receive any future issues of the VetInfo Digest as expected. We almost always send the e-mail version by the 3rd of the month and the mail version usually goes out between the 7th and 10th of the month. For some reason, we continue to have some subscribers each month who fail to receive the VetInfo Digest by e-mail, even though there is no indication on our end that the e-mail could not be delivered. Remember that you can always download the current VetInfo Digest, as well as all back issues, from the subscriber web site at www.vetinfo.com/subscriber/subscriber.html

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The opinions expressed in this newsletter are those of Michael Richards, DVM., author.
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This page was last edited 06/17/04
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