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‘orthopaedic triad’ described by Dr John Bergfeld of the Cleveland Clinic (Howard 2018). The triad consists of a famous athlete, a famous doctor and an unproven heavily hyped therapy. We can substitute well-known horse for the famous athlete. The question of responsibility for the burden of proof of efficacy is not as clear cut as what qualifies as evidence of therapeutic efficacy but it is no less important. The fundamental principle of medicine is Primum non nocere first do no harm. Even a treatment that is shown later


to neither cause harm nor impart benefit can deplete finite financial and industry resources, limiting future resources for clinical research. There is little financial incentive to conduct studies that challenge current practice. However, there is an argument that the burden of proof should be on those who profit from an intervention (Prasad and Cifu 2012). Certainly, the individual practitioner has some responsibility for evaluating the evidence that the intervention she is recommending is effective. However, since most practitioners are not trialists they should not bear complete responsibility. The practitioner should evaluate the evidence from investigators, regulatory agencies and specialty organisations before making a decision, giving sceptical consideration to promotional evidence. Most importantly, the practitioner should be willing to abandon a practice if compelling evidence refutes its efficacy. In summary, as practitioners, we are responsible for understanding the available evidence for a treatment such that when a client asks ‘How do you know that it works’? We have an answer. Medicine advances incrementally with occasional bursts


of discovery interspersed along the labourious march. The financial incentives for a veterinarian to adopt a novel


therapy can be formidable, even when the evidence is inconclusive. Anecdotes and testimonials are a starting point, not evidence. A sprinkling of caution mixed with the inevitable optimism of discovery is prudent. It is important to maintain professional credibility by


rigorously assessing the evidence. We serve both patients and customers. Customers have demands, but our oath is to our patients. If we are not cautious, an asymmetry develops


where the perceived benefit accrues to the customer while the horse bears the major burden of risk. Where the evidence is strong, make that clear and where it is equivocal or nonexistent, do not embellish. Evidence will help deconstruct the spin and separate the signal from the noise. It is tempting to jump on the novel treatment bandwagon but without evidence the ride is potentially treacherous.


JAMES C. MEYER Equine Sport Science, East Hampton, New York, USA References


Cohen, N.D. (2011) Equine Epidemiology: Counting for Something in Equine Practice, American Association of Equine Practitioners, San Antonio, Texas. pp 85-98.


Djulbegovic, B., Kumar, A., Glasziou, P.P., Perera, R., Reljic, T., Dent, L., Raftery, J., Johansen, M., Di Tanna, G.L., Miladinovic, B., Soares, H.P., Vist, G.E. and Chalmers, I. (2012) New treatments compared to established treatments in randomized trials. Cochrane Database Syst. Rev. 10, Mr000024.


Helle, N.M. (2012) Effectiveness of Cimetidine on the Size of Melanomas of 40 Grey Horses. Doctoral Thesis, Utrecht.


Howard, J. (2018) Cognitive Errors and Diagnostic Mistakes A Case- Based Guide to Critical Thinking in Medicine, Springer International Publishing, Switzerland.


Mair, T.S. and Cohen, N.D. (2003) A novel approach to epidemiological and evidence-based medicine studies in equine practice. Equine Vet. J. 35, 339-340.


McCord, K.A., Al-Shahi Salman, R., Treweek, S., Gardner, H., Strech, D., Whiteley, W., Ioannidis, J.P.A. and Hemkens, L.G. (2018) Routinely collected data for randomized trials: promises, barriers, and implications. Trials 19, 29.


Persaud, N. H. C. Novelty Bias. In Catalog of Bias [Online]. Available: https://catalogofbias.org/biases/novelty-bias/[Accessed].


Prasad, V. and Cifu, A. (2012) A medical burden of proof: towards a new ethic. BioSocieties 7, 72-87.


Prasad, V., Cifu, A. and Ioannidis, J.A. (2012) Reversals of established medical practices: evidence to abandon ship. JAMA 307, 37-38.


Yeates, J.W. (2016) Ethical principles for novel therapies in veterinary practice. J. Small Anim. Pract. 57, 67-73.


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