Thanks so much for your article Dr. Coates. I certainly hope that both pet owners and veterinarians take it to heart. I just sent off (this am in fact) a letter to JAVMA (Journal of the American Veterinary Association which is received by 80% of all veterinarians) that expresses the exact same sentiments.

My letter was a comment on the 1/15/13 article about palliative treatment of brain tumors in dogs. As you may have read in the study, over 70% of these dogs were treated with multiple drugs *before* diagnosis. Yet all of these clients were willing to have the requisite (for proper diagnosis and prognosis) advanced imaging performed on their pets (so these pet parents were among those willing to spend $$$ on their companions).

Were these pet owners properly informed of ALL of their options before treatment was begun for presumptive diagnoses? Probably not. The reality of day to day practice, as you aptly pointed out, often necessitates therapy dictated by the signs (symptoms) exhibited by the patient.

OK fine, then why oh why are some clients not given all of their options?? Should the personal opinion of the doctor regarding any particular treatment be the deciding factor? Just because I don't like treating skin (and other superficial diseases) with potentially highly toxic immunosuppressants like steroids and cyclosporine (Atopica) does that mean that I should not give my clients this option?

This is the question that the recent CT resolution strongly discouraging a treatment (homeopathy) raised.

As a trained molecular biologist, scientist and veterinary homeopath, I feel that it is my responsibility to include homeopathic treatment among the options given to my clients. It should be their informed decision about which treatment to choose.

Jeff Feinman, VMD, CVH
Certified Veterinary Homeopath
Chairman: Academy of Veterinary Homeopathy Research and Education Committee
http://www.homevet.com/about-dr-jeff

Dr. Feinman,

I'm afraid I question your suggestion that you offer, or that any veterinarian should offer, EVERY possible therapeutic option. I doubt you recommend therapies you feel are useless or do more harm than good, and you are right not to do so. And when you discuss options with clients, I am sure you give them your professional judgment regarding the risks and benefits of those options.

A key responsibility for a veterinarian is to offer guidance to their clients, and idealy this means an evidence-based assessment of the available therapeutic options. Simply because another veterinarian believes in the value of a therapy is not, in itself, sufficient reason I should be expected to offer it to my clients. Given that I believe there is overwhelming scientific evidence showing homeopathy, for example, is of no therapeutic value, it would be unethical of me to offer it just because you believe it is worthwhile. And I am sure you do not discuss the "option" of annual vaccination for a dozen different diseases just because some veterinarians still believe this is an acceptable practice.

Fully informed consent requires accurate and complete information. It does not require treating all possible therapies as equally legitimate or as reasonable options.

I agree 100% and appreciate your input Dr. McKenzie. The therapeutic options offered by a doctor should be those that have proven effective and ideally are also scientifically validated.

I would NOT withhold offering an effective treatment just because I did not understand its' scientific basis or because it was not well documented. To do so would be unethical and markedly reduce the tools that I learned both at Penn's vet and MD schools (yes, I was enrolled both in vet and MD classes as well as conducting molecular biology research).

For example, I initially balked at investigating veterinary homeopathy. In my mind it was scientifically implausible. However when I delved beneath the surface (as scientists are wont to do) and read about the extraordinary successes of homeopathic treatment in otherwise fatal epidemics (references gladly provided upon request), I felt that I needed to learn more.

I also absolutely agree that "simply because another veterinarian believes in the value of a treatment..." is not a good reason to offer it as an option. However, the converse is also absolutely true.

When clients return for my evaluation after consultation with a Board Certified veterinary specialist, I am therefore able to help scientifically evaluate *all* of their options. What *I* "believe" is not necessarily germane.

I truly appreciate the chance to bring the critical issue of properly informed consent to this public forum.

Jeff Feinman, VMD, CVH

Dr. Fineman,

I am glad we agree that our recommendations to clients should be based on the best available scientific evidence. That is an important starting point for any discussion about how we should make clinical decisions. And I certainly agree that one should not avoid recommending a therapy simply because one does not understand it or does not have sufficient knoweldge or experience to judge it.

However, with respect to homeopathy, I'm afraid it is often suggested that those of us not convinced it is effective have made this judgment in ignorance, and that is not correct. The scientific case against homeopathy is robust and has been made many times, most recently in the white paper submitted to support the resolution you referred to (http://skeptvet.com/Blog/wp-content/uploads/2012/12/Resolution3_2013_Homeopathy_Attch1.pdf).

The evidence for homeopathy has been presented by the AVH and, upon close and careful inspection, it is not compelling (http://skeptvet.com/Blog/wp-content/uploads/2013/01/The-Evidence-for-Homeopathy-A-Close-Look.pdf_). So in this case, a strong argument exists for not offering this therapy to clients because there is good evidence it is of no benefit.

In any event, while we are not likely to come to an agreement on that question, the underlying issue is what is the veterinarian's responsibility in terms of providing appropriate options and recommendations to our clients? I think we clearly have a responsibility not to withold reasonable options on the basis of cost or our own ignorance or limitations.

But I also think a primary purpose for having professional healthcare providers who are required to undergo extensive training, in science generally as well as clinical medicine in particular, is so that we can make thoughtful, evidence-based judgments about the options we offer to our clients. Our "opinions," so long as they are based on the conscientous application of our knowledge and training to the specific needs of our patients, are absolutely relevant and appropriate to offer, and in fact this is precisely what our clients are paying for.

In the digital age, especially in veterinary medicine where official regulation of products and services offered to pets is minimal, clients have the ability to identify innumerable options for treating virtually any problem their pets have. However, many of these options have not been demonstrated to be safe or effective in any scientific way, and the information available to clients most often comes from commercial sources with clear potential conflicts of interest. So veterinarians have a duty to help clients identify those treatments that are most likely to benefit their pets, and to provide as much information and analysis as possible to our clients so they can make fully informed decision.

Discouragng ineffective therapies is as much a part of our duty to protect our clients' interests as promoting those that are based on good science and being honest about the many gaps in the evidence for all of our treatments. The CVMA resolution was an expression of this duty to the public.

Hopefully, our dialogue will also help offer the public the kind of information, and yes, opinions, that they deserve to be able to consider when making decisions for their companions.

The AVH's response was indeed accurate and was a response to the white paper from CT (written by you) which has been widely recognized even in the purely conventional veterinary community as biased and one-sided.

There *is* a large body of evidence in favor of homeopathy, e.g.studies available at http://www.facultyofhomeopathy.org/research/ and http://www.carstens-stiftung.de/clinresvet/index.php and http://www.homeoinst.org/ etc..

In my integrative practice, I have experienced how homeopathy can be used to successfully treat many conditions under many circumstances. The large public outcry over the CT VMA's resolution is evidence that the public wants this option to remain available.

As per the point of this blog, if veterinarians are encouraged to offer *all* options to clients, then they are best advised to learn about CAVM modalities. Otherwise, their clients may quietly slip away and seek second opinions from practitioners with experience and knowledge in these modalities.

Dr. Jeff FEInman

As one of those owners that will go to the ends of the earth for her critters, I very much appreciate how my doctor presents options.

First, a diagnosis is attempted if time permits. However, if the doctor is sure the possible diagnosis outcomes will have no treatment options, he lays that out and will possibly suggest that there's no reason to put the critter through testing if there's nothing that can be done when we figure out the problem. If I really want the testing, he will respect that.

For instance, when my Louise had adenocarcinoma, he said that a definitive diagnosis could be accomplished with surgery. However, since he was pretty darned sure that's what she had, he suggested that we might not want to put her through it. He would have done the surgery if I had really wanted it, but he was right. There was no reason to put her through major abdominal surgery at that point.

When my Winston was finally diagnosed with lymphocytic lymphoma (after much testing and finally intestinal biopsy), he presented me with the options. We tried the standard protocol which made Winston feel terrible. He conferred with a veterinary internist to explore other options. I was presented a list of options, ranked as he felt they might help.

I also have a habit of sitting up late and surfing the web on kitty health issues. Many times I've asked about a particular thing I've found with which he isn't familiar. He'll research it and talk to other doctors. If it's a bad idea, he gently lets me know his opinion. Many times we decide on a "Can't Hurt. Might Help." methodology.

He's extremely intelligent and compassionate, but always willing to listen and take other ideas into consideration. He's also very open to having the critter see a specialist.

Yes, I want to know every option known to medical science, but I also value and respect his opinion as to what path to take.

I want information, and ideally with some context, such as the potential risk of a less aggressive treatment, what results the vet has seen in other cases if applicable, what diagnostics would have to be done to know more about the condition and whether they would change the treatment plan, and treatments the vet doesn't typically use but wants me to know are out there. And how soon should we expect to see improvement and at what point do we know we need to try something different.

It might sometimes seem like clients are difficult and demanding about information, but we have to make decisions that we might end up second-guessing for months or years, especially when we read some information that our vet didn't provide us, when it's too late.

I've been in a few situations when I think the vet was waiting for me to say the word euthanasia first, so I think we pet owners need to realize that bringing it up doesn't always mean you're making a decision, or that the vet has given up or you're out of options. The more frank you can be, the more frank your vet can be, in my experience. Especially if it's the emergency vet and not someone who knows you and your pet.

This is very timely as I just requested full lab work for one of our kitties. Two hundred dollars later I feel much, much better; and I've spend $200 on much more foolish things to make myself feel better (see also handbags, online gaming). But I definitely had to lead the conversation in that direction.

And the lab work reported back what we already knew - stable cat of unknown age with early stage renal failure. But we'd never tested his liver before, or a few other things, and I really needed to know we were doing everything we could, especially as he continues to lose weight.

But the whole thing is so situational that I don't know how a vet could possibly handle it without some lead from the client. For another cat with a different history I might have opted for something totally different.

@annet,

I'm sorry your kitty has the beginnings of renal failure. We cat people deal with that all too often. Unfortunately nothing can fix it, but hopefully your kitty does well with treatment and the disease is slowed considerably.

How's the kitty's blood pressure? All of my CRF kitties have had high blood pressure.

One of the reasons I'm a big fan of full bloodwork and a full checkup (including blood pressure) is to have a baseline so we'll know when something starts to get out of whack.

I used to wait until a kitty was 6 or 7 years old before including blood pressure in a checkup, but changed that some years ago. Thank goodness! It was a faint murmur (usually no big deal) coupled with the inability to get a blood pressure that brought one kitty's heart problem to light. Of course, there's a huge thanks that goes to a very astute vet.

Due to always doing a full blood panel, we were able to see another kitty's calcium gradually start to increase over several years. Additional tests were done and, luckily, the kitty's calcium has reverted to being normal. Had the slightly high calcium been seen on the first panel, we might have ignored it.

I'm open to almost any treatment for my pet's illness or condition. The principle which guides me is what best answers the question "how can my pet's suffering be alleviated?"

With that information, the next step is to assess how long relief will last, in context of the pet's general health, age and cost. Cost is always last on my list, but alas, it must remain a consideration.