In the dilemma discussed in the June issue of In Practice, you were presented with a lively, 60 kg dog with an obvious anterior cruciate rupture that required surgical repair. Published evidence indicated that osteotomy procedures had a higher success rate in large dogs, but in your own, self-audited experience, a lateral fabellar suture carried a high success rate. Your clinic did not offer osteotomy procedures but the owner could afford referral. Which should you chose? (IP, June 2016, vol 38, pp 310-311). David Mills noted that published evidence, with its large sample size and strong conclusions, had a sense of objectivity. However, he questioned what objectivity really meant and how useful it actually was in a medical discipline, where subjective aspects were involved, such as pain, emotion and suffering. He suggested that changing the perception of evidence-based veterinary medicine or modifying it to a repository of external evidence to be referred to if required rather than obligatorily might help to clear the ethical waters in decision making in cases such as this.
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THE vet's self-audit of lateral sutures matches published success rates for tibial plateau levelling osteotomy (TPLO), but how objective is his assessment?
Published studies (Bergh and others 2014) indicate TPLO provides better long-term outcomes on objective (force-plate) measures, and better function in the shorter-term, so referral is in the patient's interest.
When making treatment decisions, vets have an ethical imperative to consider all relevant evidence, and to assess its reliability. By assuming that vets’ self-audit of their performance is accurate, which is not always the case, and misconstruing evidence-based veterinary medicine (EBVM) as the blind application of imperfect clinical trial results to practice, Mills makes EBVM appear unethical.
Cognitive psychology demonstrates the unreliability of people's judgements in conditions of uncertainty (Kahneman 2012), and the history of human and veterinary medicine shows that practitioners routinely believe ineffective, even harmful, treatments are effective (Wotton 2006). Even today, some vets treat many diseases using homeopathy because their clinical experience convinces them that it is effective.
Because clinical trials are imperfect, EBVM explicitly assesses the quality and applicability of trial results before applying them to practice. High-quality, objective evidence ameliorates errors introduced by the subjective components of clinical experience and judgement. There are many examples of such evidence proving trusted treatments ineffective.
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