|Welcome to CIVT's new blog. We welcome contributions from current and past CIVT students as well as CIVT Faculty and CIVT members and our Facebook friends. We also welcome your comments - the best of which will be published here.
Email firstname.lastname@example.org with your missives and accompanying photos.
Building a Better Umbrella
Richard Palmquist, DVM (CIVT Faculty in Bioregulatory Medicine, Past President AHVMA, and Co-Director AHVMA Foundation)
Fundamentally, all veterinarians are seeking tools, which they can reliably use to assist them in their mission to improve animal and human health. The entire field of human and veterinary medicine could be envisioned to be 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 as a tool, we gain some insight into veterinary medicine as well.
- A tool requires a user. Someone must wield a 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 abuse a tool if she lacks good judgment and this can lead others to have a bad opinion of the tool, when in fact it was the user's abuse of that tool which 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 in its use. And knowledge of proper use coupled with good judgment allows us to use our tools
- with the greatest success. Training reduces abuse, which is a word that actually means, "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, etc. In this analogy we can well 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 that this was just the way things should be and be happy with the status quo.
- A tool can be used in less than optimal condition 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 subject 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 one 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 will accelerate. 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)
CIVT is doing an important global service to veterinarians as they organize courses in complementary and alternative and integrative veterinary medicine.
The integrative veterinary medical movement is simply taking areas of CAVM and cooperatively applying properly done researc
h to clinician expertise and experience 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 one's interest in helping others, proceeds to investigating its components and ends with the addition of knowledge that assists one's personal 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.
AHVMA Foundation. www.foundation.AHVMA.org. Accessed 2.1.12
Balla JI, Heneghan C, Glasziou P, Thompson M, Balla ME. A model for reflection for good clinical practice. J Eval Clin Pract. 2009 Dec;15(6):964-9.AVMA Guidelines for Complementary and Alternative Veterinary Medicine. Approved 2001 and updated 2007. http://www.avma.org/issues/policy/comp_alt_medicine.asp. Accessed 3.18.12.
Burgio LD. Disentangling the translational sciences: a social science perspective. Res Theory Nurs Pract. 2010;24(1):56-63.
Memon MA, Sprunger LK. Survey of colleges and schools of veterinary medicine regarding education in complementary and alternative veterinary medicine. J Am Vet Med Assoc. 2011 Sep 1;239(5):619-23.
Moore CG, Carter RE, Nietert PJ, Stewart PW. Recommendations for planning pilot studies in clinical and translational research. Clin Transl Sci. 2011 Oct;4(5):332-7. doi: 10.1111/j.1752-8062.2011.00347.x.
Murphy SA. Research methodology search filters: are they effective for locating research for evidence-based veterinary medicine in PubMed? J Med Libr Assoc. 2003 Oct;91(4):484-9.
Royal B. 2012. The Royal Treatment: A Natural Approach to Making Your Pets Wildly Healthy. Emily Bestler/Atria Books, a division of Simon and Schuster, New York. [from prerelease manuscript]
Sackett DL. Evidence-based medicine. Semin Perinatol. 1997 Feb;21(1):3-5.
Shanafelt T, Dyrbye L. Oncologist Burnout: Causes, Consequences, and Responses. J Clin Oncol. 2012 Mar 12.
Tan LB, Chinnappa S, Tan DK, Hall AS. Principles governing heart failure therapy re-examined relative to standard evidence-based medicine-driven guidelines. Expert Rev Cardiovasc Ther. 2011 Sep;9(9):1137-46.
Toews L. The information infrastructure that supports evidence-based veterinary medicine: a comparison with human medicine. J Vet Med Educ. 2011 Summer;38(2):123-34.
van den Hoonaard DK. Moving toward a three-way intersection in translational research: a sociological perspective. Qual Health Res. 2009 Dec;19(12):1783-7.
Zinsstag J, Schelling E, Waltner-Toews D, Tanner M. From "one medicine" to "one health" and systemic approaches to health and well-being. Prev Vet Med. 2011 Sep 1;101(3-4):148-56.
The Evolving Mind of Medicine
Richard Palmquist, DVM - CIVT Faculty
February 15, 2012
In 1992, only a few months after our nation and my office in Inglewood, California was rocked by the Los Angeles riots, an R&B band named En Vogue released "Free Your Mind," a song encouraging people to let go of their prejudices and see things for what they were. That song rocked a message into our minds, rose to number six on theUK charts, and the video was nominated for many awards. Eventually the video won MTV Music awards for Best R&B and Best Dance Video in 1993.
The song's chorus contains these lyrics:
"Before you can read me
You've got to learn how to see me, I said
Free your mind and the rest will follow..."
I heard this song early one morning a few weeks ago and it just stuck there playing repeatedly as I went through my activities. Usually when this happens there is a message that I need to hear, so I sang along happily for a few days, and then, as I prepared to see patients, another message replaced it:
"Free YOUR mind and Medicine will follow."
I wrote it on the white erasable board in our treatment room in big blue letters and then posted it to the AHVMA Foundation facebook page.
In my mind, En Vogue started singing again even louder. It seems there were more prejudices in the world than just race and sexual preferences. There were prejudices against scientific topics like holistic and integrative medicine.
I laughed out loud as I thought through my life.
- I recalled the first time a client asked me about herbs for treating their pet and how I dismissed the entire field as an antiquated and primitive substitute for "modern medicine."
- Then I thought about how sure I was about the dishonest, incompetent and unethical nature of so-called "holistic" doctors. I was biased against the field. The whole idea frightened me. It challenged me and my medical education.
- If an article appeared in a professional journal or my local newspaper discussing adverse side effects of alternative treatments, I would carefully save it and tell my clients how to keep themselves safe from "nonscientific medicine." If someone asked me about Chinese herbs I certainly could tell them about how herbs could be adulterated or act as poisons. Of course I had no idea how to prescribe them safely even though I regularly prescribed drugs like phenylbutazone, which I knew could cause adverse effects and even death.
- If a client gave me an article or information about alternative therapies I would just laugh and denigratingly call them "unscientific." I read three medical journals at that time and there were no articles on these subjects. I knew, or should I say, believed, that no one was doing credible research on such subjects and would point out the lack of studies to make my point. As soon as the client was gone I would toss the information into my trash can without a second thought. I felt pretty smart and smug.
- It was troubling to me when animals died and I had nothing more to offer, but I carefully fixed my mind so that it never connected anything I heard about alternative therapies with those treatment failures. And if a pet I was treating unsuccessfully recovered after seeing an integrative or holistic veterinarian, I was sure it was just coincidence. After all, I was trained in one of the best veterinary schools in theUnited States and if something worked they would have taught me.
Not once during that entire time did I ever go to a medical library or go on-line and look to see what articles I might find on the subject. I certainly never asked a clinician who practiced these modalities out to lunch to find out why and how they were practicing. It was easier not to do so. It was safe to stay in my own little exam room with no challenges to my belief structure or professional knowledge base.
But Life depends upon the advancement of truth and it has a way of rubbing our noses into things when we make errors. First we are presented with gentle reminders by clients and other professionals. Then things get stronger. Finally one day things get to the point where we can no longer fail to look, fail to examine, and seek the real truth about a subject. When I finally did, I learned I was ignorant. I discovered my ego had blocked my understanding and ability to reach and discover new things. I realized I had failed to follow the advice my science-oriented parents had drummed into me for my entire childhood.
I had decided without looking. I believed I knew all about something without studying it. My pride and prejudice fueled by fear made me guilty of scientific cardinal sins.
But when I looked, I found a whole series of tools that could benefit my patients who I truly loved and desired to help. For tools like acupuncture there were plenty of scientific references and studies by major universities like UCLA. In those days, it was hard to learn this material. There were no journals, few classes, and no lectures at major national veterinary conferences. It took study and dedication to comprehend Chinese concepts that made my mind stretch and my head ache. It soon became evident that such work could take an entire lifetime to learn.
I was humbled. And a bit depressed.
And then a gentle man told me the secret. He said, "No one knows it all. Nor can anyone ever hope to. Learn what you can and use it to help your patients and as you do that they will teach you many things. Learn those things and share them with others. That is how we advance our understanding. That process is an art called medicine. And we PRACTICE it because we can never master it."
And so I changed my mind. And as the song says, the rest followed.
When we seek truth we find it. As we find it we must recognize it, validate it, and confront how it fits together to improve patient outcomes. This is the evolution of medicine we are witnessing now. Briefly, that evolution looks like this:
- Traditional Medicine. One person cares about another and tries different things to help them. They teach their knowledge to their families and to others in their profession. Sometimes this information is written down, but often it consists of a verbal history. Because humankind co-evolved with nature, this form of medicine develops interdependent relationships with natural substances.
- Authoritarian Healing. A few people are recognized as experts in a field and they teach others.
- Scientific Medicine. Scientific methods are applied to better understand anatomy, physiology, biochemistry and pharmacology and how information can be applied to healing and health.
- Evidence-Based Medicine (EBM) is defined by Sackett as "the integration of best research evidence with clinical expertise and patient values." Using scientific method and improved methods of data evaluation this movement rose in an effort to improve the evidence and thereby the results of medicine offered by professionals. It has limitations, though, because it depends upon clinical trials and often fails to know things until long after they are evident and in use by others. It is a useful and important concept, but may stop the progress of new ideas.
- Integrative Medicine. As evidence accumulates therapies are integrated into practice, which is an expected progression of scientific medicine's investigation into Traditional healing.
- Translational Medicine. This field is the natural progression of medical research and practice. In it the fields of scientific inquiry and interventional epidemiology unite in more cohesive forms to use evidence-based medical principles to investigate and develop medical advances more rapidly and efficiently. It seeks to improve patient care by correctly seeking and applying all information about that area of medicine. In the future every reputable veterinary school will have a translational medical chair.
A veterinarian practicing today has the benefit of so much research, which is readily available to anyone who will sit down and search the diverse medical literature. And we need even more. Life is such a broad activity and veterinary medicine is responsible for handling such a large part of it that all of us can easily spend our lifetimes involved in a cooperative effort to improve our tools. The time to deny things because we don't know about them is over. The time to look, to demand research, and work to create new models that help us understand and improve healing is here.
Clinicians know that our patients and clients want solutions for their unique problems. As we open our minds and cooperate with others inside and outside our fields, we learn that there is a better way for medicine to progress. The entire One-Health concept is the manifestation of this precise effort.
The sooner we change OUR minds, the sooner our patients will benefit and that is something we can all look forward to seeing.
Veterinary Oncology: Balancing Quality and Quantity of Life
Richard Palmquist, DVM - CIVT Faculty
January 4, 2012
It was summer. The wind rushed through my hair as my bike sailed down the street at top speed. In my youthful exuberance – which was far more concerned with the outcome of beating my best friend home than with the consequences of my actions – I raced ahead while looking back at my friend. As I looked forward and plummeted past the stop sign and into the intersection, I saw that large Cadillac speeding towards me on a direct intercept. My father was gardening in our front yard and looked up just in time to see me skid sideways and slide under the car's front bumper. The wide-eyed woman driver somehow masterfully avoided a fatal crash, and my bike went under her wheel sparing me totally. Her car skidded loudly to a stop as I stood up, unharmed, to dust off the accident and see my father walking sternly over to me.
Knowing punishment approached I yelled out, "I am OK, I am fine. I am not dead."
The woman relaxed, but my father did not. "Just because you didn't die does not mean that your actions were optimal. You must consider the effects your decisions create," he said.
I thought of this story today while considering the new trend in human and veterinary cancer research, which considers not only survival times of patients receiving various treatments, but also the quality of life they experience as they proceed down their therapeutic path. Veterinarians have long considered quality of life in management of our patients. As veterinarians, we regularly balance and weigh a treatment's theoretical mechanism of action, its scientific evidence, its likely outcomes and its cost, as well as the ability of the human beings in the environment to do the actions necessary for a successful outcome. Evaluating quality of life objectively is a new scientific endeavor and it can be a bit tricky. A group of integrative veterinarians at the AHVMA Foundation recently formed a group to do just this and it will be interesting to see where the research leads.
Pet owners are concerned with these same factors and they often voice concern over how a treatment will affect the animal's quality of life. In many cases people tell me, "I am more concerned over quality of life than absolute length of life," and that makes perfect sense to me. The veterinary professional literature is now beginning to discuss the ethics of various therapies and how veterinarians and clients can properly communicate to be certain that clients are provided with sufficient information to make decisions about their pet's care. Many years ago, the acid test was simply which treatment allowed the most days of survival for patients undergoing that therapy, but now evidence and research have advanced sufficiently that we are asking more sophisticated questions and gaining understanding of more issues than simply how many days a patient might be expected to live.
From the client's perspective, upon learning that their beloved animal friend has a tumor, they will want to take a moment to breathe and then begin to assemble the best team possible to address their pet's health care.
Below are some commonly asked questions and statements by clients to veterinarians regarding cancer treatment in animals. They can be important issues which should be addressed before deciding upon a course of therapy for an animal (or human) with cancer:
- What is the expected outcome with no treatment? This is important data, as before a potential therapy can be evaluated, the client needs to have some idea as to the normal course of a disease. The difficult thing about answering this question is that often we have no formal studies that document this fact. And no two oncology patients are the same, so a study looking at hundreds of patients still does not predict the life expectancy of a single patient with that diagnosis. If the average or mean survival time from diagnosis is 110 days that could mean that one pet lived 12 hours and another lived five years with the others falling somewhere in between.
- What treatment options are available? Animal guardians want to know what their options really are and we all need to recognize that oncology is continually changing based on new information. Furthermore, no one veterinarian probably knows all the options, especially when we begin to consider integrative and complementary and alternative veterinary medical options. We may need to seek out multiple sources to answer these questions. I recommend first consulting with a board certified veterinary oncologist and then seeing an integrative veterinarian with a good reputation to discuss these options. Other Internet and library searches may provide further data to consider. Professionals should be supportive of the client's quest for the best therapy.
- How often do you treat this type of cancer? Some cancers are quite rare and have little data available about their behavior. In such cases both veterinarians clients may need to do more research before choosing a treatment course.
- What evidence exists for each option? What is the anticipated survival? What is the quality of life of patients undergoing that treatment plan? There are differing levels of evidence. An undocumented story on the Internet is not a very dependable source. A support group may be more reliable than a site selling the latest greatest magic bullet cure all. Clients should be advised to be very suspicious of any internet site that promises cure. Most of these are flat out false and deceiving. A group of people with similar experiences can be better but is still not as accurate as more sophisticated, controlled and randomized blinded clinical trials. But clinical trials can be faulty, and research methods can be distorted which can make for difficult choices. Specialists tend to be the best sources of research data, but if things have not been published then they may not have access to new treatments or untested therapies. Professional team members can help clarify these issues and that makes life much easier for everyone. Finding professionals that clients can trust is a critical part of selecting successful therapy.
- What are the common adverse effects anticipated, how frequent are they, and what can be done about them to minimize their severity? Treating cancer can result in discomfort and clients should learn how to recognize and address the commonly expected outcomes of their pet's therapy. Proper nutrition can greatly assist in managing such outcomes and good nutrition is the foundation of all good medical care. Homeopathics, herbs, acupuncture, chiropractic and rehab therapies can all assist but we need to know about interactions and safe use of these special forms of care. Clients should always disclose all therapies to all the professionals on their team and encourage the team to talk with one another if there are questions. Veterinary medicine has evolved to the point where we have excellent medications for managing nausea and pain and if we consider the use of integrative therapies then many patients can live very happily with advanced disease states.
- Does the proposed therapy expose the client's family or other pets to any dangers? Many chemotherapy drugs present a danger and require special handling. They can pass in the urine and stool and can accumulate in the environment or cause danger if skin exposure or ingestion occurs. Discuss any safe guards needed to protect the client's household.
- What are the costs for each option? Since treating cancer can be so complicated, it is unlikely that anyone can predict the total costs for therapy. After all, in cases where a patient lives much longer, the costs can be correspondingly higher. But professionals should always be happy to help answer this question to the best of their ability.
- If this was your pet what would you do? Veterinarians have an obligation to objectively educate clients about their options. Most good doctors do not want to mislead or misrepresent the options and will discuss them openly. Often times the evidence is unclear and the decision is confusing. Clients need to take responsibility for their own decision but ask the professional this question to see how they answer. This can be helpful in the overall process, but clients should understand that they're simply asking for a personal decision and the veterinarian's answer can reflect their understanding and experience as well as their personal bias.
- Ask about complementary or alternative or integrative therapies and for the name of local practitioners the specialist trusts. Many good oncologists have relationships with local practitioners that have developed over long periods of time. It's important that the health care team can speak openly and solve problems.
Thanks to modern advances many forms of cancer can be successfully addressed. In many cases we cannot cure a disease, but we have tools that allow patients to live better and longer than ever before. Each patient is different and each disease is unique as well. When we consider that each cancer patients is a genetically unique Being with a totally unique environmental history, we can begin to see why individualized, integrative care is so critical to achieving successful outcomes. The key to success is open and honest communication – and trust – between the client and the veterinarian, and for the client to be allowed to take their time to make the choices they can best live with. And as my dad said there are more things to consider than just how long we live. It's what we can do FOR a patient that matters, not what we can do TO them.
- Lynch S, Savary-Bataille K, Leeuw B, Argyle DJ. Development of a questionnaire assessing health-related quality-of-life in dogs and cats with cancer. Vet Comp Oncol. 2011 Sep;9(3):172-82. doi: 10.1111/j.1476-5829.2010.00244.x. http://www.ncbi.nlm.nih.gov/pubmed/21848620
- Giménez F, Hecht S, Craig LE, Legendre AM. Early detection, aggressive therapy: optimizing the management of feline mammary masses. J Feline Med Surg. 2010 Mar;12(3):214-24. Review http://www.ncbi.nlm.nih.gov/pubmed/20193912
- Looney A. Oncology pain in veterinary patients. Top Companion Anim Med. 2010 Feb;25(1):32-44. Review.
- Bowles DB, Robson MC, Galloway PE, Walker L. Owner's perception of carboplatin in conjunction with other palliative treatments for cancer therapy. J Small Anim Pract. 2010 Feb;51(2):104-12.
- Palmquist RE, Goldstein R. 2009. Case report: Longer than expected survival using a novel, integrative approach to hospice in a case of canine osteosarcoma with apparent chest metastasis treated with therapeutic nutrition and homotoxicology. JAHVMA. 28 (1): 16-25.