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Do we have the evidence for the evidence base?

by
01 August 2015, at 12:00am

THE MERCURY COLUMN in which a guest columnist takes the temperature of the profession – and the world around

HAVING just finished reading last month’s edition of Veterinary Practice – and a jolly good read it was – one article stood out for me and has stayed with me ever since: the piece by David Williams asking if it is “Time for a less cut and dried approach?”

In this piece, Dr Williams argues for a marriage between the art and the science of veterinary medicine and I find myself running up the aisle behind them, shooing them along to have the marriage blessed as soon as possible before anyone appears at the back of the church to provide a cogent argument why the union should not take place.

Of course there are countless veterinary surgeons who practise the art alongside the science on a daily basis but I worry about the human tendency to follow herd behaviour and the inherent dangers that lie in the widespread adoption of “best practice” just because someone important said so.

History and the annals of the press (sometimes I wonder if the correct spelling might be misleading) are littered with cases where an overenthusiastic adherence to a widely accepted professional standard may have driven common sense from the scene of the crime.

Something being done commonly in a certain way allows us, as mere mortals, to feel confident in glossing over the detail where there may be good reason to stop and take stock before pressing forward.

Medical jurisprudence and that of the benighted social care system can provide a myriad of such instances, as can an historical examination of, for example, teaching or policing in the UK.

If we’re honest with ourselves, the manner in which the veterinary profession has lent its name to the handling of the foot-and-mouth outbreak in 2001 or the recent badger culling arrangements has failed to signal a cohesive approach to a watching public and, as we all know, professional standards are hard to refine and even harder to apply when politics and the press enter the profession’s bedchamber.

Dr Williams’ question of whether we should generalise from one example to all by developing a logical set of rules to apply to all situations rings particularly loudly for me as I spend much of my time watching the interface between veterinary practice and the consumers who support it.

Public expectation

Perhaps not unreasonably, the public feels it has a right to expect this profession to take the lead in areas where our collective knowledge and exposure to holistic information should equip us to provide some leadership of opinion but ethically, all veterinary surgeons should feel free to express their own views and our failure to speak with one voice could easily be misinterpreted as disengagement.

History has shown us that what is best practice today can become a museum piece of procedure tomorrow and most families today can bear witness to the medical consequences of tonsillectomy, hysterectomy and the complete removal of all healthy teeth as all having been best practice in previous times. In their own way, all would have been seen as having been led by the available evidence of the time.

Perhaps that’s where the problem lies with the current, widespread enthusiasm for evidence-based medicine – the danger is to see any snapshot of the best available evidence as being the holy grail of evidence or, worse still, to see a lengthy recital of various published papers as being persuasive by virtue of sheer volume in a “never mind the quality, feel the width” moment.

Talking to colleagues who know much more about proper science than I do, their fear is that some organisations and individuals can, and perhaps do, see EBM as a passport to enhanced status and may hijack the terminology.

Simply citing copious references doesn’t make it good science and, without the ability or even the time to read and assess the many references, it is dangerous to accept either the printed or spoken recommendation as being good science.

We are told that people crave leadership even more than veracity and, in selecting our leaders, we seek and are willing to recognise and endorse persuasive discourse on subjects which are important to us.

However, even when someone takes a leadership position in the interpretation of the available evidence, we are faced with the very human problem of assessing how much we feel we can rely on the humility of the person assuming that role.

We need to see some humility in anyone assuming that position to be able to trust them on a human level. This is all the more important if, as is the situation within veterinary medicine, the body of knowledge is expanding faster than any one person’s ability to read and assess the mass of information.

This has led to a monitorial system of information dissemination – as an example, consumers want to know why the profession is tacitly endorsing badger culling in certain areas; many of us rarely see a badger and have little or any first-hand experience of the spread of bovine tuberculosis.

Necessarily, we need to assess the available information but need leadership to interpret arcane or conflicting data. If we adopt the party line, even if we know what the party line is, we are already in conflict with the luxurious position to which we still cling avidly, whereby each veterinary surgeon should feel free to assess the information and declare their own, considered opinion.

Recent correspondence in the veterinary press makes it clear that there is divided opinion on the available data concerning the management of the badger population, so it becomes easier to avoid situations where we are required to commit to an informed position.

That’s largely what we did with the issues of feline injection site sarcoma and for appropriate vaccination intervals for cats and dogs because it became too difficult to interpret the data. One could argue this has led to a number of sequelae with business and social ramifications for our client base.

When done properly, EBM is a powerful and highly valuable tool but we fool ourselves if we think a casual acquaintance with the concept will be enough.

In the meantime, the absence of a cohesive, unified position on key issues continues to leave the consumer without a leader in animal healthcare issues and, as a profession, perhaps we should be careful what we ask for.