Comments on fixing the debt

I read with interest the letter¹ on educational debt from Dr. John Baker, dean of the College of Veterinary Medicine at Michigan State University. In his letter, Dr. Baker describes the college's efforts to address the problem of educational indebtedness by decreasing “the number of preveterinary requirements to 55 credits,” which would allow students to enter the veterinary college after 2 years, or even 1 year, of undergraduate education.

When I attended Purdue some 30 years ago, similar requirements were in effect. Many of my classmates with only 2 years of undergraduate work have gone on to have very distinguished careers in the profession; certainly in the classroom they were the equal of any student with a bachelor's degree. Nonetheless, several have told me they felt they missed something along the way. I treasure my bachelor's degree from the University of Connecticut as much as my veterinary degree. I learned so much from the non-prerequisite classes, including classes in literature, sociology, and history. In short, I got a great liberal arts education, not simply a ticket to veterinary school, and feel so much the richer for it.

With respect to costs, it is worth noting that undergraduate tuition at the University of Connecticut for in-state students this year is $10,524. By contrast, veterinary tuition for out-of-state students is > $50,000 at Michigan State University and most other schools. My younger colleagues in our practice tell me that their undergraduate tuition was manageable but that veterinary college tuition is why they are overwhelmed by debt. Given that even for in-state students, veterinary college tuition is typically 2 to 3 times undergraduate tuition, it is clear that veterinary college tuition is a much more substantial factor in creating student debt.

Finally, I question the granting of a bachelor's degree along with a veterinary degree, at the completion of the veterinary curriculum, to Michigan State University students with 55 undergraduate credits. I found my undergraduate degree to be more difficult to obtain—while maintaining the necessary grade point average—than my veterinary degree. I question why a student with less than half an undergraduate education should get the same degree as one who fulfills the 4-year degree requirement.

Ed Grace, dvm

Coventry, Conn

As a 1958 graduate of the Michigan State University College of Veterinary Medicine who has had a productive professional life and is still practicing some 58 years later, I felt it was appropriate to comment on the recent letter from Dr. John Baker¹ on updated prerequisite education requirements for veterinary college applicants at the university. I completed my preveterinary requirements in 2 years at Michigan State and was accepted into the veterinary college on my first application. I decided on a career as a veterinarian at age 6. At that time, John Hannah was university president and started the Honours College. If an undergraduate received all A's in any quarter, the student was accepted to the Honours College and was able to take any class on campus, with permission of the instructor, as long as the student fulfilled all the requirements for his or her declared major. Students could take as many courses as would fit into their schedule. I pursued my interests in anthropology, botany, and ceramics, taking some 25 credits each quarter, and during the summer quarter, I completed some of the first-year veterinary curriculum so I could pursue graduate ceramics along with anatomy. The program was a great opportunity to receive an education that has nourished me to this day. My interest and training in anthropology have been a great help in working as a veterinarian with clients from other cultures as well as working with primates. The university is there to be used by students. I realize that education is expensive and appreciate efforts to minimize the cost, but if we want graduates to have a successful, productive life and contribute to society, we must encourage the growth of all their interests. The university setting is the perfect place to do so, and there must be a way for this to happen. If not, the number of veterinary college graduates leaving the profession will be higher than it is at this time.

I know the veterinary curriculum is demanding with a huge amount of material to learn, but we must consider the long-term effects of the educational system in place at this time and its effect on students. I would love to see a requirement for 1 course in the humanities each quarter added to the curriculum. Music, art, and social sciences would all be of great value in producing well-rounded graduates.

James M. Harris, dvm

Sandy Bay, Tasmania, Australia

Veterinary homeopathy's place in the profession

We would like to address a few points raised by the recent JAVMA News article, “A closer look at veterinary homeopathy.”¹

According to Dr. Virginia R. Fajt, a clinical associate professor of veterinary physiology and pharmacology, “our current understanding of chemistry, physics, and pharmacology precludes any scientific basis for the efficacy of homeopathy.” We believe, however, that this represents an outdated and limited understanding of the relevant research and discourages broader, more innovative thinking. We refer readers to the article “Homeopathy in the treatment of gastrointestinal conditions in animals: part 1—what is homeopathy?,”² which contains a synopsis of our understanding of the mechanisms of action of homeopathic medicines.

We also suggest that the arguments made by Drs. David Ramey and Danny Chambers concerning the ethics of homeopathic treatment are not unidirectional and that the implications that only homeopathic treatments fail and that all conventional treatments are evidence based are incorrect. In fact, 1 reason so many veterinarians are turning to complementary and alternative modalities such as homeopathy is frustration with the limited number of effective treatment options currently available. We take seriously our obligations “to do some good” and “to provide effective treatments.”

Regarding Dr. Ramey's comment on the indirect harm associated with “people wasting resources on ineffective treatments and ineffective treatment precluding application of effective treatments,” we disagree with the pervasive assumption that harm is acceptable as long as standard diagnostic and treatment protocols are being followed. We often see cases deemed incurable after the owners have incurred thousands of dollars in diagnostic and medical expenses. Many of these animals are dealing with the side effects of previous treatments. Although, under current standards of care, these animals would not be considered to have received inadequate care, we have been left “to pick up the pieces,” to quote Dr. Chambers.

We would also like to emphasize that the use of homeopathy is not necessarily an either-or proposition. In fact, quite often homeopathic prescriptions are integrated with the conventional care patients are receiving. If a patient improves when homeopathic care is instituted, then consideration is given to weaning the patient off conventional medications.

Finally, it is our wish that less time will be devoted to disparaging homeopathy and more time will be devoted to examining additional healing possibilities for our patients. Case reports^3,4 of patients with serious diseases that were healthy after homeopathic treatment suggest that these types of medical intervention may indeed have an effect. With the rising interest in complementary and alternative modalities, including homeopathy, more veterinarians are learning that our patients can only have the best outcomes if we consider all therapeutic options.

Shelley R. Epstein, vmd

Wilmington Animal Hospital

Wilmington, Del

Jeffrey M. Feinman, vmd

Weston, Conn

I wish to commend Malinda Larkin on her exceptionally balanced JAVMA News story, “A closer look at veterinary homeopathy: what is the modality's place in the profession?”¹ Our profession needs to honestly and openly evaluate any modality purporting to treat a medical condition, lest we be accused of being only profit driven.

As a student attending a guest lecture on homeopathy in veterinary school, I suggested that 80% of conditions could resolve without treatment or, in some cases, despite conventional medical treatment, and asked how we could know, therefore, whether highly dilute homeopathic preparations truly have any medical benefits for animals. The speaker answered that homeopathy works best when the owner believes that it works. I responded that this appeared to be the very definition of the placebo effect.

Years later, I recalled this conversation as I read a Wall Street Journal article by Shirley Wang entitled “Why placebos work wonders.”² In short, according to the article, many controlled studies appear to show that even though placebos do not change the underlying illness, they may have an effect on how we experience and respond to conditions such as depression, inflammatory bowel syndrome, infertility, and obesity. Positive expectations of efficacy make placebos appear to be effective, and even when study participants were told they were being given an inert treatment, they often experienced improvement due to “mind-body self-healing processes.” But, whether veterinarians should be legally able to sell the sizzle, not just the steak, remains a valid question.

Pam Milligan, dvm

Chattahoochee Veterinary

Cleveland, Ga

The recent JAVMA News report “A closer look at veterinary homeopathy: what is the modality's place in the profession?”¹ led off with an anecdote describing a dog that couldn't walk but was reportedly normal 6 months later, after receiving homeopathic treatment. Rather than supporting the efficacy of homeopathy, however, the story was more likely an illustration of the caregiver placebo effect.² It is clear that the practitioner perceived a benefit in the homeopathic treatment given to the dog, but it is unclear whether the client also experienced a caregiver placebo effect and it seems certain that the patient did not benefit from the placebo effect. Until there is good evidence that veterinary patients can experience and benefit from placebo effects, which to date have only been documented in humans, there is, in my opinion, no place for placebo treatments in veterinary medicine.

Homeopathy is appropriately considered a form of alternative medicine. This designation indicates approaches to medicine that have not been shown to be efficacious or that do not have the theoretical basis required to be considered part of mainstream, science-based medicine. In contrast to mainstream medicine, which is based on physics, chemistry, and biology, homeopathy is based on principles that do not match our current understanding of these fields.

Admittedly, it can be difficult to assess the legitimacy of each of the infinite number of potential treatments, each based on an infinite number of potential rationales, available in the field of medicine. In 2014, the AVMA's House of Delegates declined to pass a resolution discouraging the use of homeopathy, saying that the Association should not take a position specific to a particular modality¹ and apparently trusting that veterinarians, on the basis of their scientific training, would be able to steer clear of ineffective modalities. Despite the difficulties in assessing the legitimacy of various modalities, it seems clear that modalities based on principles that conflict with current knowledge of physics, chemistry, and biology can be considered ineffective. This would include acupuncture, which has not repudiated its ancient biological rationale.

It is time to decide what the “sound, accepted principles of veterinary medicine”³ are and what they are not. For the AVMA and state veterinary medical boards, it is time to get real.

Edmund K. LeGrand, dvm, phd

Crossville, Tenn

Thank you for publishing the JAVMA News story “A closer look at veterinary homeopathy: what is the modality's place in the profession.”¹ The report opens by describing Dr. Monique Maniet's experience with a dog that became ill a week after receiving a Lyme disease vaccine and that was back to normal after 6 months of homeopathic treatment. Similar stories are commonplace among most veterinary homeopaths, and homeopathy is used by millions of people and animals worldwide.

I don't believe that the quote from the Russian Academy of Sciences declaring homeopathy “unscientific and ineffective” is relevant, because most European countries recognize and endorse homeopathy. Homeopathy gained recognition during the late 1800s and early 1900s in the United States and abroad when it was used during outbreaks of cholera, yellow fever, and malaria. In the early 1900s, 1 of 4 physicians in the United States was a homeopath, and a statue of Dr. Samuel Hahnemann, the founder of homeopathy, stands in Washington, DC, today near the White House. This was the first statue in Washington, DC, dedicated to a physician and the first dedicated to a foreigner who was not involved in the American Revolution. Unfortunately, homeopathy's history is largely unknown to the conventional medical community and general public.

The current focus in both veterinary and human medicine is on vaccination as the gold standard for inducing immunity. Many Academy of Veterinary Homeopathy members use vaccines in clinical practice, although typically following a minimalist approach, with only core vaccines given early in life, followed by measurement of antibody titers and reliance on duration of immunity. As a group, we are not opposed to vaccines and vaccination, just to the misuse of these elements of preventive medicine. Vaccine inserts clearly and specifically state that vaccines are to be administered only to healthy animals, yet to my knowledge, this principle is frequently disregarded at many practices across the country. It is my personal belief that vaccinating unhealthy animals represents poor judgment and can cause enormous harm. We should strive to optimize a preventive disease approach for each animal, depending on the animal's current health status and risk level.

Todd Cooney, dvm, ms

President, Academy of Veterinary Homeopathy

Kokomo, Ind

Addressing chronic hunger

Programs that focus on attempts to alleviate world hunger and malnutrition¹ are, I believe, inevitably doomed to failure if we don't also address a world population that is rapidly outstripping the carrying capacity of the Earth. This can be dealt with humanely through reproductive planning and education, or mother nature will control it with plagues, environmental degradation, natural disasters, famine, and wars, etc. I would certainly opt for the more humane approach.

Jerome Berkowitz, dvm

Paola, Kan

More research needed on malingering by animal proxy

Malingering by animal proxy (MAP) refers to owners or caretakers purposefully pretending an animal is ill, or actually inducing illness in an animal, to obtain veterinary medication for personal abuse¹ or monetary gain.² The current prevalence of MAP in veterinary settings is unknown, but we have identified 5 cases of MAP reported in the professional forensic psychiatry literature.¹ LeBourgeois et al¹ reported that in all their cases of MAP, clients presented with dogs and falsely stated that the dogs had various health problems (eg, cough, noise phobia, and malnutrition) for the purpose of acquiring a range of drugs (eg, opiates, thyroid supplements, and antidepressants). Despite being uncommon and difficult to identify,² MAP carries serious ramifications and has the potential to negatively impact animal welfare as a result of unnecessary veterinary treatment.

More recently, a media report³ discussed MAP for the principal purpose of gaining drugs or syringes. This report also made note of the fact that MAP can coexist with other disorders. For example, owners of pets used in MAP might visit several veterinary practices (veterinary shopping) and even deliberately injure the animals to obtain drugs. Similar behaviors are seen with Munchausen by proxy, in which the maltreatment is in the service of obtaining attention, care, and control over others.⁴ It is possible that reported signs of Munchausen by proxy could apply to animals that are harmed rather than people.

We need to point out that the only report of MAP was published > 10 years ago, yet MAP continues. Although the prevalence is likely to be low, further research is needed to better define and expand our knowledge of this phenomenon. Furthermore, with the expansion of telemedicine and the ability to purchase veterinary drugs online, deceptions involving MAP are likely to increase.

Veterinary staff who dispense medication need to be made aware of MAP and should receive relevant training, including information on reporting such incidents. The authors believe that more clarity, especially for veterinary professionals, is required to recognize disorders that seem similar but vary in deliberateness and motivation (eg, hypochondriasis, MAP, and Munchausen by proxy). LeBourgeois et al¹ suggested that training of veterinarians by psychiatrists could help veterinarians and their staff in detecting and dealing with such behaviors. This suggestion mirrors education efforts covering similar areas that encompass human mental health and pet abuse.⁴

James Oxley, mres

Essex, England

Lori Kogan, phd

Department of Clinical Sciences

Colorado State University

Fort Collins, Colo

Marc Feldman, md

University of Alabama

Tuscaloosa, Ala