Thursday 15 November 2012

Dear Vet...

Dear Vet,

Let's start with the basics - this comes from your professional code of conduct and I am confident its something that you haven't forgotten and try to abide by:

"I PROMISE AND SOLEMNLY DECLARE that I will pursue the work of my profession with integrity and accept my responsibilities to the public, my clients, the profession and the Royal College of Veterinary Surgeons, and that, ABOVE ALL, my constant endeavour will be to ensure the health and welfare of animals committed to my care."

Your profession has been given an absolute legal responsibility for diagnosing and treating animals - a vet is the ONLY person who may do this in the UK. Your profession gives you unassailable authority (no matter what your personal level of experience or interest). That gives you incredible rights - and also incredible responsibility.

Let's talk for a minute about evidence based medicine. This is a term which you vets have borrowed from human medical practice and its something which your governing body is actively promoting.

Evidence based medicine is: "the use of current best evidence in making decisions about the care of individual patients...[it] means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

Sackett, D.L. et al (1996). Evidence based medicine: what it is and what it isn't. BMJ, 312, 71-72

In this same article, the authors give an example of how evidence-based medicine works in practice:

"Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. 

...Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the “gold standard” for judging whether a treatment does more good than harm. 

However, some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we must follow the trail to the next best external evidence and work from there."

This is a pretty rigorous approach to clinical practice. It requires curiosity, analysis and a willingness to question not only the professionals with whom you work but the outcomes of your own practice.

Randomised controlled trials (or RCTs - the "gold standard" which the article describes) are much less common in veterinary medicine than in the human field and are likely to remain so. However, there are other effective ways of gathering evidence.
The RCVS states:"The fundamental tenet of Evidence-based Veterinary Medicine is that the practice of medicine should be based on valid, clinically relevant research data, whenever available. This is in preference to the traditional method of medical training—still in sway—that is weighted more toward authoritative “experts,” espousing their best judgments".

In other words, what isn't adequate, particularly in this day and age, is to coast along and do the same as you've always done - what you were taught as a student or by a mentor - even if this is done with the best of intentions.

I know that you are taught nothing about barefoot at veterinary college (I know this because I had an email from a frustrated current student at the Royal Veterinary College last week) but honestly, its just not enough any more to ignore hooves simply because they are outside your comfort zone. Nor is it acceptable to prescribe bar shoes and wedges in the face of evidence that they can cause hoof capsule damage and pain.

I will hold my hands up and agree that there isn't much evidence which assesses barefoot horses at the moment - but I've been emailing updates from the blog to the vets of the horses here (many of whom have been extremely supportive) for years now and if you want the records of the horses who have been at Rockley you have only to ask.

There is increasing evidence in the human field that barefoot is more therapeutic than unproven, untested, unresearched running shoes. You will also find that increasing numbers of your colleagues (including the author of this paper) are educating themselves about barefoot performance and discovering its benefits for hoof health.

But when it comes to horses with pain in the back of the foot, DDFT and collateral ligament injuries and navicular bone damage (the sorts of horses we have here for rehab) then the research has been out there for years:  and the outcomes with conventional treatments are poor.

As the article above says, successful interventions for otherwise fatal conditions don't require RCTs so why wouldn't you at least consider the evidence for a different approach - particularly a non-invasive, reversible one - for a condition which so often means the end of the horse's working life? Its got to be better than a neurectomy or months of box rest, after all.

I'm not saying there are guarantees, I am not saying that barefoot will always be successful and no-one would say it was easy (it does of course involve a lot more than just taking shoes off), but you should at least assess the evidence.  No one will object to you comparing it to evidence for other therapies - in fact that is exactly what you ought to be doing - along with recording what is effective and what isn't.

When you are considering hooves you need to look at how they are functioning, how they are loading, how and why they can change (don't neglect nutritional factors!), whether they are working at the biomechanical optimum and how shoes or barefoot are affecting that before you exercise your undoubted power. Please be systematic and look at the evidence - don't just do what you have always done.

Yours faithfully,

Nic Barker


Krista said...

LOVE this. It's so very true and I consider myself lucky that my vet has been so supportive and wants to learn more but we really need more vets to come on board so that more horses aren't written off unnecessarily.

amandap said...

Great post Nic. x

Calm, Forward, Straight said...

Recently heard a quote that I think is applicable here..

"The plural of anecdote is data."

I've got a happily and healthily barefoot (three years now) tb who had all the usual tb weak foot issues. No sole, shelly, white line disease... the first week I had him home I had to pull his shoes myself as he partially yanked one off. That was not fun.

I was initially told it was a waste of my time to try, but if I insisted then my horse would surely need costly (and impossible to maintain in my remote location) hoof casting.

Thank goodness I came across your book and website. I am now learning to do intermediate trims between farrier visits, and we recently took a walk down an aggressive gravel road just a few hours after a trim.

Thanks for all you do. :D

Molly's hoof blog said...

You are doing fantastic work. The systematic documentation of the horses in your care, and how nature would form their hooves, I think is really unique and so important. Keep up the good work and thanks for sharing!

Jassy Mackenzie said...

Wonderful letter! Wish there was some veterinary journal that could circulate it worldwide!

cptrayes said...

I really didn't think you'd be having to write that five years after you started your blog :-(

But it is still needed, unfortunately.


Nic Barker said...

Calm Forward Straight - I love that quote :-) Absolutely spot on!

Thanks for all the great comments - of course evidence based practice goes a lot wider than barefoot and although it is taking a while to become entrenched in the veterinary mindset it has to be the way forward.