Damming The Info Flow

Larry Bramlage, DVM, MS, Diplomate of the American College of Veterinary Surgeons, was one of the industry leaders who was asked to provide veterinary comment on editor Kimberly S. Herbert's September Viewpoint urging the veterinary community to provide information from the research laboratory and the field to veterinarians and horse owners in a more expedient manner. Bramlage practices at the Rood and Riddle Equine Hospital in Lexington, Ky., and is on the AAEP Editorial Advisory Board to the magazine.

In the December issue of The Horse, Wayne McIlwraith, BVSc, PhD, Diplomate ACVS, head of Equine Sciences at Colorado State University and another member of the AAEP Editorial Advisory Board to The Horse, offered his views on the process of peer reviewing and publishing research prior to information reaching the practicing veterinarian and the horse-owning public. McIlwraith noted, "We equine clinicians and researchers all have our frustrations with the peer review system, but it could be severely deleterious to the horse if we bypassed it."

Following are Bramlage's comments:

By Larry Bramlage, DVM

In a recent Viewpoint editorial, Editor Kim Herbert took to task the process of peer review as being an obstacle to the access of horse owners to information for the care of their horses. In the editorial, it is stated that withholding information from one sick horse too long is justification for immediate release of all research findings in advance of and in spite of the peer review process. The peer review process is condemned as a tradition and a self-service process for authors to advance their careers and to get funding. The writers and lay journalists are portrayed as the purveyors of truth who are crusading to uncover this information held hostage.

As the outgoing chairman of the Educational Programs Committee of the American Association of Equine Practitioners, an organization, incidentally, that uses the peer review process in selecting the information to be presented at its annual meeting and published in its yearly proceedings, I feel compelled to come to the defense of the peer review process.

The accusation that researchers are territorial and therefore withholding information for some type of personal gain is unfounded. The statement that "sometimes breakthroughs in equine health care are made, yet they are reported in obscure or esoteric publications, sometimes in foreign countries" is an even more difficult to understand accusation.

The peer review process is a process which developed in order to verify the validity of information. Publication in peer review journals is considered the best way to verify the accuracy of research, and therefore is the only way of establishing validity that is considered by universities when one is applying for promotion or advancement. It is the best available method for scrutiny of new information.

I would say that it would be difficult, if not impossible, to find a breakthrough in equine health care that awaited publication in an obscure publication or foreign country before professionals in the United States had access to the information. For every instance of delayed publication that has occurred, I will name you two instances of premature publication that, not only did not improve the health of the horse, but in fact, sometimes actually hurt horses by their use.

I will give you two noteworthy examples from the American Association of Equine Practitioners meeting, prior to our initiation of the peer review process.

The flushing of guttural pouches with hydrogen peroxide was presented at one AAEP meeting before peer review acceptance for papers at the meeting was initiated. It was subsequently determined to be more harmful than helpful because it actually was damaging the nerves to horses' throats and airways, creating more problems than it resolved.

In addition, literally hundreds of horses were made to undergo aggressive and severe anterior hoof wall resection for the treatment of laminitis when, in fact, the long-term results for that treatment eventually showed that it was more harmful than helpful in most cases of laminitis. If follow-up documentation of claims were required, as is now the case with peer review, many horses would have been spared harm from useless, painful procedures.

If any group of people needs the aid of the peer review process to substantiate the information used in the treatment of animals, it is the horse-owning public. Never in my 21 years of practice can I remember there being so much activity in the area of what we somewhat loosely term "alternative medicine." The number of "energy field readers, animal psychics," or "chiropractors" of every size, shape, and discipline, and the number of "black box salesmen" that ply their trade on a daily basis to the horse population is greater now than ever. Dr. William Tiznik, a nutritionist at Ohio State during my tenure there, had a saying: "Benjamin Franklin said that, 'a fool and his money are soon parted,' but the equine corollary was that, 'it was morally wrong to allow a fool to keep his money.' "

It amazes me that the horse-owning public is so cavalier about what they do to their animals, and that they literally stand in line to have their animals undergo treatments which are medically unsupported by data, poorly documented in many instances, questionable for the health of their horse, and expensive. Yet every rumor magazine story, fancy sales pitch, and idea loosely borrowed from human medicine that comes down the pike seems to have willing takers and users.

At the AAEP, we are continuously struggling with how to verify some of the treatments advocated by these alternative health care providers. Our membership, in some instances, even embraces questionable treatment methods that we are trying to validate, largely with little success. The only consolation is that the more tightly regulated and the more highly policed area of human medicine is having the same trouble that we are.

The snake oil salesman is not dead.

If someone approaches you with a new, secret, or phenomenal cure, ask for some validating information before you use it. Beware of claims of publications in foreign, obscure journals. Almost all good journals are at least abstracted in the United States.

And don't fall for the claim that "we don't know how it works, but it works for me." If someone can't at least give you a plausible explanation of the mechanism, don't accept the claims.

Good information contains 1) a definitive number of subjects it was used to treat (50, 35, 151, etc., not "over 1,000"), and 2) a consistent measuring assessment graded on a scale of numbers to establish efficacy.

If you are just spending money to make you feel like you're doing something for your horse, give it to research.

The peer review process is the only way that validity of information can reasonably be established. And, in spite of the peer review process, I would wager that every magazine that contains 10 newly discovered cures in an issue will only have one of those newly discovered cures stand both the test of time and the process of peer review and make it into the veterinary armament for use in high-quality equine medicine and surgery.

The editor states in her article in reference to the horse owner that knowledge is power. So is gunpowder, but as one can understand, applied knowledge can both be helpful and dangerous. So, I think taking the veterinary community to task in the method in which she did is unjustified. The peer review process is the only available method that has proven to be worthwhile in assessing the quality of information as it surfaces.

In the practical sense, that peer review process has combined with the test of time to determine which veterinary treatments are of sufficient merit to gain access to the armament of equine medicine and surgery. Breakthroughs are not made every day, but when a significant breakthrough is made, if you attend a number of veterinary meetings, you will see reports of that discovery over and over and over again. The statement that it is at all to the investigator's advantage to hide a discovery is false. In fact, the more widely the investigator publishes the discovery, the more likely he is to obtain further funding. Funding is not obtained by holding back on what you've found.

To be more fair-handed in this response, we do need to take to task the process of getting information to print that she addresses. A one- to two-year delay between submission and publication is a truly unacceptable delay.

But fortunately, many of the journals have agreed to allow publication of abstracts and not consider them as prior publication of material. Therefore, the delay imposed by the printing process is often circumvented by meetings such as the annual convention of the American Association of Equine Practitioners, where the information is presented prior to publication of the complete manuscript in the peer-reviewed journals.

In addition, the trend of the peer reviewed journals to become more and more "exclusive" in many instances excludes articles of high significance because the journals follow an esoteric pursuit in the attempt to become the most exclusive of the veterinary publications. From a practitioner's sense, it is easy to identify these journals. They have taken the wrong turn when they are riddled with submissions in excess of their capacity. They shift to such strict criteria for acceptance in their statistical analysis that the investigation is difficult to follow.

Often the articles are an investigation of a problem that is of little or no clinical significance. The space within the journal also is progressively filled with case reports that lend little or no help to the day-to-day practice of veterinary medicine.

So, I would like to chastise the journals as well as the lay press for being on the opposite ends of the spectrum.

Most classic articles in veterinary and human medicine were generated from large-volume, high-quality investigative work of clinical or experimental nature where the author was allowed to discuss the findings frankly and at length, and to wax about their significance and the possible mechanisms of the disease. By doing so, the pathogenesis of many diseases becomes unraveled. To be sure, scientific minutia is an important part of the learning process as well, but the journal must be willing to bridge the gap between laboratory statistics and the end user animal.

Frustration exists on many sides of the problem. But to throw out the process is not fruitful either.

So, as with so many systems, policies, mechanisms, and traditions, the peer review system has its flaws, but it is the best process that we have of establishing scientific validity and is not simply a "damming of the information flow."

About the Author

Larry Bramlage, DVM, MS, Dipl. ACVS

Larry Bramlage, DVM, MS, Dipl. ACVS, practices at the Rood and Riddle Equine Hospital in Lexington, Ky.

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