There is a principle in all branches of medicine that dates back to Hippocrates, the ancient Greek physician. It has come to be known as “Primum Non Nocere” – “first, do no harm”. In many ways, this is the basis of all modern veterinary medicine . Before you start any treatment or intervention, make sure that doing it will improve the patient’s state, not worsen it. But how does that research link into the real world of you and your pet?
Table of contents
- Why am I thinking of this now?
- Isn’t this something for vets and researchers only?
- What can animal owners do?
Why am I thinking of this now?
Well, at the moment there is a big push on Evidence Based Veterinary Medicine, or EBVM. That’s what the British Veterinary Association’s Manifesto on Evidence Based Medicine is all about, as I explained in an earlier blog.
The idea is that we should only carry out treatments that we know are effective, because there is a reliable evidence base. In other words, that treatment has been studied and we know that it is likely to be more effective than any alternative drugs or methods. Because anything else is potentially ineffective or even harmful, and certainly wastes your money.
A really good example of this is the famous EPIC trial, the results of which were published a few years back. This study, which followed dogs with heart disease at 36 different centres across the world, has conclusively demonstrated that the drug Pimobendan delays the onset of heart failure in dogs with heart disease, even if given before they develop any symptoms.
We looked at who you could trust in a previous blog – but how do we as vets and animal owners apply this in practice?
Well, there are three basic approaches to using EBVM in the real world.
1) No intervention should be attempted unless there is a large body of good quality research supporting it.
Although in strictly scientific terms, this is correct, it is a little uncomfortable for many of us because there are a number of procedures that definitely seem to work that we don’t have good evidence for. We routinely give antibiotics for wounds that look infected, without taking a swab to confirm that they are. Should we stop? My gut call is that if we did, we’d lose a lot more patients to sepsis than we currently do. In the real world, this is a little unrealistic.
2) If it seems to you that it works, use it.
The trouble with this is that it misses the whole point of EBVM. That’s when you end up treating you patients, and killing them without realising that you were responsible.
3) Use the best evidence there is.
This, I think, is the best halfway house argument. It accepts that the principles of EBVM are sound, but also that the world isn’t perfect.
My colleagues and I are failing our clients – you – and our patients if we aren’t regularly checking whether there is an evidence base for something we’re thinking about doing. And contrary to popular opinion, yes, we do change our minds. Some of the techniques I was taught by genuine experts in the field when I was a vet student I wouldn’t dream of doing now. Not because they’re out of fashion, but because they’ve been proven not to work. There are things that I earnestly advised my clients that I now am a lot more nuanced about, because as more evidence has come in, we’ve discovered that there are better options. Or at least, that the situation is more complex than we once thought.
So yes, we should always be using the ebay evidence there is. And if there isn’t solid evidence that a treatment works, we should be using our knowledge of anatomy, physiology and biochemistry (which yes, we are all trained in) to determine if it really could work.
However, it isn’t enough on its own!
4) Gather more evidence
We always need more data – compared to human medicine, there are very, very few good quality large scale trials. So as a clinician, if I treat a patient and something unexpected happens. I should be reporting it (or even writing it up). But even more importantly, we need to be working with our colleagues in academia to build these single case reports into larger datasets. Properly conducted trials, to find out what works and what really doesn’t.
Isn’t this something for vets and researchers only?
I don’t think so. What we need is more, and better, research done in practice – done in the real world, with real patients, to identify real problems and how to fix them. The biggest barriers to practice-based research have always been:
● Ethical oversight. It’s really important that any research is carried out ethically. Therefore an ethics committee is needed to check that the researchers aren’t getting carried away. Until 2016, that meant going to a university – and they were famously reluctant to grant oversight to anyone who wasn’t working for them. That has now changed, and the Royal College of Veterinary Surgeons, our regulator, is now offering Ethics Review for in-practice research. If you want to know more, check out their page here.
● Client consent. Most owners are unwilling to allow their pet to be “experimented on”. Well, modern research doesn’t work like that. The way modern clinical research works is to select two groups of patients with the same condition. One group (the control group) receives the current “best practice” or “gold standard” treatment. The other group is then given the new experimental treatment, but otherwise they are treated identically. Then, at the end of the trial, researchers compare the two groups without (crucially) knowing which is which.
What can animal owners do?
So, this is my appeal to you. If you want us to get better at what we do, and to find out which treatments are wasting your money, and which are saving lives, you need to be involved. If your vet offers your pet a place in a trial – please think seriously about taking it. We all need better evidence to base our treatments on!
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