Recruiting clients to a referral center
I found the recent report by Drs. Herron and Lord1 regarding use of a clinical behavior service at a companion animal specialty referral practice to be problematic, in that the authors' findings could be interpreted as advocating that veterinarians working in a clinical behavior service recommend that their clients bypass their regular general practice veterinarians when considering whether to bring their animals to a specialty practice for treatment of other conditions. Considering that 62% of the dogs in the study had been referred by general practice veterinarians, I think that this would be an unfortunate situation.
I maintained a specialty referral practice for nearly 40 years and would never consider taking a blood sample for testing without first obtaining permission from the referring veterinarian. Alternatively, I would have clients return to their regular veterinarian to have the blood sample collected and tested, with the results forwarded to me by the referring veterinarian. My rationale was that even if my specialty hospital would have benefitted financially, maintaining a good relationship with referring veterinarians was more important.
The concluding paragraph of the report refers to “recruitment of clients to a referral practice.” That seems like a faulty strategy if one wishes to continue to receive referrals.
Seth A. Koch, VMD, MSc, DACVO
Philadelphia, Pa.
1. Herron ME, Lord LK. Use of and satisfaction of pet owners with a clinical behavior service in a companion animal specialty referral practice. J Am Vet Med Assoc 2012; 241:1463–1466.
The authors respond:
Thank you for sharing your concern that the idea of recruiting clients to a veterinary specialty referral practice might give the impression that the authors were advocating that general practitioners be bypassed in the referral process. I wholeheartedly agree that the referring veterinarian should be central to the decision process when a client is considering seeking care from any veterinary specialty service. The referring veterinarian should also be included in the diagnostic process and be informed of the treatment details. In fact, the Behavioral Medicine Clinic at The Ohio State University Veterinary Medical Center informs referring veterinarians of every case seen, even if the case was not a direct referral. In most instances, we also refer the animal back to the general practitioner for further diagnostic testing when indicated. The description of our findings was in no way intended to suggest that referring veterinarians should be bypassed when making the decision for a pet to visit another specialty service. We mainly hoped to show that having behavioral medicine as a specialty option in a referral practice may bring repeat business to that same referral center, rather than losing the client to a competing referral center, should the pet owner or referring veterinarian find a visit to another specialty service necessary.
Meghan E. Herron, DVM, DACVB
Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio.
Complementary and alternative medicine
In his recent letter, Dr. Palmquist1 disagrees with our statement2 that research studies funded by the National Center for Complementary and Alternative Medicine have generally not found any reproducible effects by pointing to a study of the short-term effectiveness of glucosamine and chondroitin sulfate in human patients with knee osteoarthritis. Importantly, this was not a study of complementary or alternative medicine, in that the substances tested are merely conventional pharmaceutical agents. It is only through a bit of legislative alchemy that these compounds are sold as supplements in the United States and European Union without first requiring proof of safety and efficacy.
Furthermore, although Dr. Palmquist cites the initial finding of better pain relief with glucosamine–chondroitin sulfate for patients with moderate to severe pain, more recent reports3,4 contradict these findings, with one3 concluding, “At 2 years, no treatment achieved a predefined threshold of clinically important difference in [joint space width] loss as compared with placebo,” and the other4 concluding, “Over 2 years, no treatment achieved a clinically important difference in [Western Ontario and McMaster University osteoarthritis index] pain or function as compared with placebo.” Thus, we stand by our earlier statement that NCCAM's efforts have generated “almost nothing that has…any reproducible effects on patients.”
In her response to our letter,5 Dr. Shelley Epstein appeals to a proposed distinction between vitalistic and mechanistic approaches to medicine. However, we fail to see how this aids in the scrutiny of homeopathy and similar complementary and alternative medicine practices. Regardless of how they describe it, homeopaths claim that homeopathy has effects in the real world. That is, they claim that, when faced with sick patients, homeopathic remedies can cause a recognizable change in those patients over time. Controlled trials of homeopathy in which bias and the opportunity for mistaken impressions have been eliminated have consistently shown that homeopathic remedies have no greater effects than placebos.
As clinicians, we must accept that the evidence of our eyes can be deceiving. If objective evidence from controlled trials tells us that a particular therapy is no better than a placebo, we have a duty to accept that evidence and move on to other modes of treatment. We also have a duty to learn from valid criticism, regardless of the source. In her letter, Dr. Epstein complains that an undercover investigation of homeopaths in and around London was performed by skeptics of homeopathy, but does not address the substantive issues that were raised.
The British Veterinary Association has said in its submission to the Medicines and Healthcare Products Regulatory Agency regarding the licensing of homeopathic products, “Wild extrapolation of [a] disproven human therapeutic modality to animals is … an offence to animal welfare.”6 Veterinarians have an ethical responsibility to their patients to provide safe and effective treatments. We do not believe that providing ineffective treatments for animals fulfills this responsibility.
Simon J. Baker, MA, VetMB, PhD
House and Jackson Veterinary Surgeons, Blackmore, Essex, England.
Gordon J. Baker, BVSc, PhD, DACVS
Professor Emeritus of Equine Medicine and Surgery, University of Illinois, Urbana, Ill.
1. Palmquist RE. Complementary and alternative medicine merits further exploration (lett). J Am Vet Med Assoc 2012; 241:1560–1561.
2. Baker SJ, Baker GJ. Pragmatic versus philosophical evaluation of complementary and alternative medicine (lett). J Am Vet Med Assoc 2012; 241:1146.
3. Sawitzke AD, Shi H, Finco MF, et al. The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the Glucosamine/chondroitin Arthritis Intervention Trial. Arthritis Rheum 2008; 58:3183–3191.
4. Sawitzke AD, Shi H, Finco MF, et al. Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT. Ann Rheum Dis 2010; 69:1459–1464.
5. Epstein SR. Complementary and alternative medicine merits further exploration (lett). J Am Vet Med Assoc 2012; 241:1561.
6. UK Parliament. Memorandum submitted by the Medicines and Healthcare Products Regulatory Agency. Available at: www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/09113010.htm. Accessed Nov 27, 2012.
