Quiet time

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While Ryan enjoys the hustle and bustle of Antigua I am enjoying the quiet and solitude in the Honduran jungle. Earlier today I suspected the hotel had no other guests and that maybe the staff had evaporated in to the mist as well. Still not fearing for my life or how I would obtain clean towles I explored the grounds and hiked along the river. Both are extremely tranquil and gorgegous. N

Mola Mola

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Irsquove only had one day off diving since I last wrote and even then I spent the day shopping for dive equipment. I now have a new mask that doesnrsquot hurt my nose like my old one and itrsquos really small so feels like I can see a lot more underwater which is always a bonus. I have also ordered a new wetsuit as Irsquove started to get cold in the 27 degrees water. Hard to believe I kno

A Different Path to Medical School – New York Times (blog)

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Special Challenges of Science-Based Veterinary Medicine

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On this site there have been several thoughtful posts (e.g. by Dr. Atwood and by Dr. Novella), and subsequently much heated commentary, on the distinction between Evidence-Based Medicine (EBM) and Science-Based Medicine (SBM). I agree wholeheartedly with the position that the two are not mutually exclusive, and that SBM is essentially EBM as it should be practiced, with a comprehensive consideration of all relevant evidence, including the subject of plausibility. As a practicing veterinarian, and an officer of the Evidence-Based Veterinary Medicine Association (EBVMA), I am keenly interested in bringing to my profession a greater reliance on high quality research evidence and sound scientific judgment, and reducing the reliance on individual practitioner intuition and experience in making clinical decisions. However, those of us in veterinary medicine face some special challenges which make the subtle but important distinction between EBM and SBM especially salient. 

Where’s the Evidence?

The first of these challenges is the paucity of high quality clinical research evidence. As an example, in his 2007 book Snake Oil Science, R. Barker Bausell examined the research evidence concerning the use of glucosamine as a treatment for osteoarthritis in humans. He was able to analyze the strengths and weaknesses of a Cochrane Review which included 20 studies with 2570 patients (the most recent revision of this review includes 25 studies with 4963 patients), a NEJM study with 1583 patients, and an Annals of Internal Medicine study with 222 patients treated for two years. His conclusion was that the intervention was not more effective than placebo.

I recently did a targeted search of the PubMed literature database for a brief evidence-based medicine feature on the subject of glucosamine and chondroitin as treatment for osteoarthritis in dogs, currently in press at the Journal of the American Veterinary Medical Association. A search of the terms “glucosamine,” “arthritis,” and “dog” yielded eight references, of which three were relevant (a more comprehensive search strategy yielded sixteen references, but only the same three were relevant to the clinical question). The three useful references included two clinical trials involving a total of 113 dogs and each lasting about 2 months, and a systematic review of treatments for canine osteoarthritis which evaluated one of these two clinical studies. Predictably, the larger, better designed trial with objective measurement criteria showed no benefit of glucosamine, while the smaller, less well-controlled trial with only subjective criteria and a 23% dropout rate in the glucosamine group showed some benefit at some assessment points.

Where’s the Money?

Glucosamine is an extremely popular, and profitable, supplement routinely recommended by veterinarians and administered by owners to their geriatric dogs. Yet the clinical trial evidence concerning its effects is nearly non-existent. The depth of the evidence is no better for many, many routine clinical interventions in veterinary medicine. The primary reason for this is simple: money. 

Obviously, the health of companion animals is not as high a societal priority as human health. Many countries have little or no formal companion animal medicine at all, of course, much less high quality, evidence-based pet medicine. And even in the developed world, the absolute size of the veterinary medical profession and associated industries is dwarfed by that of the human medical industry. 

In the United States, surveys show that most dog and cat owners have come to consider their pets to be members of their family, and their willingness to pay for veterinary care has increased along with this shift in attitude. The same appears to be the case in Europe and other developed nations. This has allowed the quality and technological sophistication of veterinary care to increase. 

Pharmaceutical companies have followed this trend, increasing their financial investment in their own internal research activities, as well as funding the lion’s share of companion animal health research generally (with all the ethical and practical problems that creates). Pfizer, the largest fish in the “Big Pharma” pond, claims to spend $300 million annually on veterinary research globally, for both companion and agricultural animals. However, the company is expected to spend $9-$9.6 billion this year on its human research and development. The same pattern is true of government research spending. Veterinary medicine will always be the poor stepchild of medicine, and we cannot expect to have anything close to the quantity or quality of research evidence available to MDs trying to practice evidence-based medicine. 

A Pack of Lone Wolves?

Another barrier to effective utilization of research evidence in veterinary medicine may be demographic and cultural. In the United States, the average veterinary practice has fewer than three veterinarians, and between one-third and one-half of veterinarians are self-employed practice owners. And most companion animal veterinarians are general practitioners, only about 10-15% of practicing vets being board-certified, with the extended academic training and, hopefully, greater awareness of and respect for research evidence that might be expected to come from this training.

As a profession, we veterinarians tend to be entrepreneurial, self-reliant, and independent. This contributes to a reluctance to let anyone tell us what to do, which may be how veterinarians perceive the position of evidence-based medicine. There is no solid data on the subject (though I am involved in a survey study which will hopefully provide some soon), but in discussions with colleagues I have sensed a great deal of anxiety about the notion of “cookbook medicine” which disdains the hard-won wisdom and experience of the individual clinician. Veterinarians are reluctant to accept the idea that there may be broadly applicable standards of care they ought to adhere to, even if their personal judgment conflicts with the evidence for these.

Undoubtedly, our colleagues in human medicine share a similar temperament and similar sorts of anxieties about “cookbook medicine”. However, these may be tempered to some extent by more widespread advanced training, more structured and supervised practice environments, and greater assessment and monitoring of outcomes, which may partially explain the greater acceptance of EBM in the human medical profession. And though the case of Dr. Rolando Arafiles, Jr. illustrates the weaknesses in the systems for monitoring physician behavior, I think it is clear that the influence of government regulation, and the threat of litigation, give the concept of adhering to a recognized medical standard of care far greater teeth in the field of human medicine than it has in veterinary medicine.

SBM, EBM, or OBM?

So how does this relate to the difference between SBM and EBM? Well, traditionally the scarcity of clinical trial evidence has led veterinarians to practice primarily opinion-based medicine. Personal experience and intuition and the opinions of individual experts or mentors are the predominant foundations for clinical decision-making. There is little or no outcome assessment, so veterinarians must rely on their own clinical experience to judge whether their practices are effective. 

The negative consequences of these strategies are many. There is dramatic inconsistency in the diagnosis and treatment of even common diseases. I routinely have to explain to my clients that if they ask ten vets a question, they are likely to get seven or eight different answers. You can imagine how frustrating this is for them, and how little confidence it inspires in our expertise.

OBM Leads Kids to the Hard Stuff, FBM!

As most readers of this blog likely already know, there are many reasons why individual judgment is an unreliable guide to the true efficacy of a medical intervention, and why we should be reticent to entirely trust our own intuitions and experience. But opinion-based medicine is also a “gateway drug” to faith-based medicine, otherwise known as complementary or alternative medicine. If you are accustomed to judging the safety and efficacy of interventions on the basis of the cases you have seen personally or the opinions of “experts,” you are more likely to be persuaded by the individual experiences of clinicians promoting and alternative practice, and more likely to think that giving it a try yourself is the most reliable way to know if it really works or not. 

The Internet abounds with holistic veterinarians who claim they started their careers as scientific, skeptical doctors but that their frustration with the limitations of mainstream medicine and the problems they could not solve led them to experiment with, and ultimately become promoters of, faith-based miracle therapies of every kind that share no theoretical or practical features in common other than being validated primarily by testimonial and not consistent with scientific knowledge or evidence. 

Tooth Fairy Science exists in veterinary medicine, but it is less of a problem than the simple lack of research evidence and the consequent reliance on even less trustworthy forms of evidence. So veterinary medicine needs a science-based approach even more desperately than human medicine because we have so little clinical trial evidence to rely on, and so few resources to generate more and better evidence. The tragedy of money and talent wasted on studying therapies that have vitalist theoretical foundations inconsistent with established scientific knowledge is even more poignant in the relatively impoverished world of companion animal medical research. Plausibility must play an important role in deciding how we allocate the scarce resources we have in order to maximize the useful information we can generate, and the subsequent clinical benefits for our patients.

Towards a One Health Approach

Veterinarians must also take advantage of the evidence that our colleagues in human medicine have generated for us. There are serious dangers in extrapolating research evidence across species, of course, but we cannot afford to entirely ignore the wealth of human medical research that is relevant to our patients. Examined cautiously and judiciously, this data can help us target our own research efforts more efficiently. Just as animal models have an important role, despite their limitations, in human health research, so human clinical research can inform veterinary medicine. As clinicians, we can make more science-based decisions, even when relevant veterinary research is lacking, if we are aware of the research in humans that already exists on the conditions and interventions we are considering. 

If glucosamine is shown to be no more than a placebo after years of research in thousands of people, how much money and effort should we invest in studying its effects in dogs? And how strongly should we promote it to our clients, the vast majority of whom must pay for their pet’s care out of pocket, without insurance coverage, and who commonly must eschew needed care or even euthanize their companions for want of money to pay medical costs?

A Worthy Goal

There has been a steady growth in the quality and sophistication of care available to companion animals in the last several decades, and I am hopeful that this will continue. But I believe the interests of our patients and clients will be best served if the care we provide is as soundly science-based as possible. And while I think evidence-based medicine can become the standard in the veterinary field, with beneficial effects on the quality of the care we provide, we need the additional features of the science-based medicine approach even more than our MD colleagues: a respect for the importance of plausibility in allocating research resources and an understanding of the need to integrate all relevant evidence when making clinical decisions about interventions in the face of a scarcity of high quality clinical trial research. 

Despite all the histrionic accusations of some alternative medicine advocates about mainstream veterinarians being tools of the pharmaceutical industry or reluctant to accept unconventional approaches only out of closed-minded prejudice or a fear for our income, the reality is that we care deeply for our patients and want to provide them with the best care we can. I truly believe, and I hope the profession as a whole will come to accept, that science-based medicine is far more likely to help us do so than the opinion-based medicine we have traditionally relied on.


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Split on the libertarian Right – Washington State GOP Primary for Senate

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GOP libertarians Palin and Paul back Didier; GOP libertarian DeMint goes with Rossi

From Eric Dondero:

Both Sarah Palin and Ron Paul have enthusiastically endorsed the candidacy of former NFL great Clint Didier for US Senate, against incumbent Dem Patty Murray. Now a stunner. Jim DeMint, a stalwart libertarian-conservative and Tea Party leader has endorsed Didier's opponent Dino Rossi.

From the Seattle PI:

Sen. Jim DeMint of South Carolina, a Tea Party champion from the GOP right, is endorsing Republican Dino Rossi in his bid to unseat three-term Democratic Sen. Patty Murray.

DeMint has been backing anti-establishment insurgents in Republican primaries: He supported libertarian Rand Paul for the Kentucky Senate nomination, and former legislator Sharron Angle in Nevada.

"When I met with Dino a couple months ago, he made it clear he was only interested in running if Republicans were serious about saving our country from fiscal collapse," DeMint said in a statement.

Ross is a former two-time GOP nominee for WA Governor against Christine Gregoire. Polls show Rossi and Didier in a virtual dead heat, but both ahead by 2 to 3 points over Murray.

Note - the Republican Liberty Caucus, which represents the libertarian wing of the GOP, has not made an endorsement in this primary race.

Ron Johnson for Senate says Feingold opposes Victory in Afghanistan

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From Eric Dondero:

A conservative blog out of Wisconsin had the opportunity to interview libertarian Republican for US Senate Ron Johnson. The Republican Senate candidate challenging Russ Feingold is heavily backed by fiscal conservative stalwart Sen. Jim DeMint.

George Will in a syndicated column last month called Johnson an a hardline capitalist and Ayn Rand devotee: "the idea of running for office never crossed Ron Johnson's mind. He was, however, dry tinder -- he calls Ayn Rand's "Atlas Shrugged" his "foundational book." His main focus as a candidate has been the country's enormous debt and cutting the tax burden for Americans, and small business. But now Johnson's giving indications on his foreign policy beliefs, as well. They are indeed views that clash with those of ultra-leftist "Moveon.org" backed Russ Feingold.

LettersinaBottle blog:

I’m very concerned about President Obama, the way he even announced the strategy, the fact that he announces the surge and the next sentence after that, he says, “Oh, by the way, we’re going to pull out in 16 months.” To me, the Taliban strategy is to surge 16 months and a day. And particularly in a conflict like Afghanistan, where we need the villagers to feel confident that, you know, whoever – that we’re going to be there for victory and that we’re committed to that. Because let’s face it, we’ve got the Taliban that’ll happily move into those villages and, you know, enact some retribution on anybody that sided with the other side. So, my concern is that President Obama has set us up for failure, quite honestly; and that’s not what you do when you’re going to commit our fine young men and women into battle. So, you know, highly concerned about his particular strategy.

I would like to achieve victory in Afghanistan. I mean, I’d like to finish off the job; I mean, I’d like to be able to say that, you know, we’ve cleaned up another nest of terrorists, quite honestly. But I’m just, again, very concerned about the direction of, you know, this policy under this president. The only thing that kind of keeps me supportive of it is the fact that we have David Petraeus. Which, by the way, Russ Feingold was one of only twenty Senators that refused to condemn the ad by Moveon.org that called him “David Betray-us.” I don’t think that’s a real way – a real shining moment in Senator Feingold’s voting record, quite honestly.

Center-Right Parties surge to lead in Sweden

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Swedish Democrats look to enter Parliament

By Clifford F. Thies

In 2006, a four-party, center-right coalition achieved a wafer thin majority in the Swedish national parliament. Almost immediately, the Social Democrats and their erstwhile coalition partners - the Left Party and the Greens - surged to a lead in opinions polls. Progress in restoring the Swedish economy to a market-orientation appeared to be in jeopardy.

According to the Wall Street Journal / Heritage Foundation index of economic freedom, the Swedish economy had dramatically improved from 61 in 1995 to 70 in 2005. During the most recent years, it has improved further, to 72 in the latest assessment. In contrast, the United States economy, which had improved from 77 in 1995 to 79 in 2001, and, further improved to 81 in 2009, fell back to 78 after the first year of the new Obama Administration. With even more regulations and tax increases enacted this year, the economic freedom rating of the U.S. is sure to fall even further in the next assessment. Would the socialist left accomplish in Sweden what it is accomplishing in the United States in terms of rolling back market-oriented reforms and ruining the economy? Or, would the center-right parties rebound so as to be able, after this September’s election, to continue to advance the reform agenda, possibility to overtake the emerging USSA (United Socialist States of America)?

As the accompanying chart shows, the parties of the center-right in Sweden, now to include the Democratic Party, have jumped ahead of the parties of the left. These parties include the four parties currently forming the ruling coalition (the Christian Democrats and the Center, Moderate and Peoples parties), as well as the Democrats. The largest party of these five is the Moderate Party. This party is a neo-liberal party, i.e., a fusion of market-liberalism and conservatism. It refers to itself as the “New Moderates” because its aim is to revive the market as well as other social-intermediating institutions of a free society within a country that had become famous not only for democratic-socialism, but for the breakdown of the economic vibrancy, family and community life previously associated with the Swedish people.

Among the potential problems for organizing a five-party coalition is the issue of immigration. The Center Party, which was formerly a party representing agrarian interests, has evolved into something of a libertarian party, representing small business interests as well as small landholders. It is also a green party, being favorably disposed to issuing green cards to immigrants. The Peoples Party, a market liberal party, has also evolved into something of a libertarian party, and favors the integration of immigrants into Swedish life, including establishing language and work requirements. The Democrats, on the other hand, come across as opposing immigration. It may be possible to reconcile these divergent viewpoints; but, as the Dutch are showing us, it may be difficult.