For a long time, going back almost to the beginning of this blog eight and a half years ago, I’ve referred to the “bait and switch” of alternative medicine. What I mean by that is the manner in which advocates of alternative medicine—or, as they like to call it these days, “complementary and alternative medicine” (CAM) or, more recently still, “integrative medicine”—co-opt perfectly science-based modalities like diet, nutrition, and exercise as being somehow “alternative.” Alternatively, they woo-ify such science-based modalities and then claim them as CAM. Either way, they deceptively give the impression of a much greater data base supporting CAM than there really is, because they’ve leavened it with all sorts of co-opted modalities that are really unremarkably part of medicine of the sort that primary care doctors routinely give to their patients to help with hypertension, type II diabetes, and other chronic health conditions. That’s why, whenever I see an example of this sort of “bait and switch,” I’m tempted to blog about it. Sometimes, I even give in to that temptation.
This is one of those times.
I’m referring to a post from a couple of weeks ago at that wretched hive of scum and quackery, The Huffington Post, by its Senior Editor, Healthy Living. (Geez, her very title fits in with HuffPo’s tendency towards woo.) Its very title promotes the message I’m talking about, Traditional Doctors, Alternative Treatments: An Intersection? The false dichotomy begins right at the very beginning of the post:
Sometimes it can seem as though complementary/alternative treatments and traditional medicine live in two silos — never the twain shall meet, as the saying goes. We go to the doctor when we’re sick or for regular wellness checks. And we go to the yoga studio or a meditation class. Yet we don’t talk to our doctors about how one can support the other.
Let’s put it this way. Stripped of all its Eastern mystical trappings, yoga is nothing more than a system of exercise, and using exercise to treat various conditions is science-based. Be that as it may, Shocker (I love writing that name) points out that a recent study in Archives of Internal Medicine reported that 3% of people seeking “mind/body treatments,” such as yoga, meditation, tai chi, deep breathing and progressive muscle relaxation, are doing so based on a referral from a real medical provider, as opposed to fake medical providers such as naturopaths, chiropractors, or reiki masters. One thing I noticed about this study is that it’s over two years old; so I’m not sure why Shocker is making such a big deal out of it now. It’s old news. Whatever. Personally, I don’t think this study is anything to be particularly proud of. Shocker labors mightily to convince you that it is. She fails.
That doesn’t stop her from moving on to trying to represent “mind-body therapies” as representing a groundswell among physicians. The only thing she gets right, by and large, is that this is largely a patient-driven, not a physician-driven, phenomenon. It’s rather like the National Center for Complementary and Alternative Medicine (NCCAM) that way. Scientists didn’t want it. Scientists didn’t see a need for it. Politicians did, and woo-friendly politicians like Senator Tom Harkin made sure that Americans got it. Boy, did we ever get it: a Center right in the very middle of the heart of biomedical research in the U.S. dedicated at its very formation to the study and legitimization of pseudoscience and quackery.
Ironically, Shocker might have inadvertently hit on one reason for this phenomenon and one reason why physicians might be willing to refer their patients for something that is almost certain not to help them: Frustration, laziness, inability to spend enough time with a patient in counseling:
The researchers also found that the patients who were seeking out mind-body treatments at the recommendation of a medical provider were those who typically had more diagnosed conditions and used the health-care system more often. Nerurkar says one reason that may be is that providers are referring their more complex patients once other treatments have failed — and this concept may lead to future research studies about what would happen if these complementary programs were offered earlier on in the treatment process.
Not to mention a seeming new willingness to prescribe placebo medicine:
Of course, not all complementary and alternative treatments have evidence behind them, Nerurkar points out. But when the research that is out there is coupled with patients’ success stories, some providers are opening up to the possibilities. “Ultimately you just want your patients to feel better,” she says. “At the end of the day, if my patients are using these therapies and they’re feeling good, I encourage them to do it.”
In other words, I don’t care if it’s science-based or not, just as long as it gives the patient the illusion that things are better.
A better discussion of the whole issue of what to do when patients want CAM therapies can be found in Medscape, entitled What to Do When a Patient Wants ‘Alternative’ Medicine. Unfortunately, even though this article is definitely better (how could it not be better than a HuffPo article?) it nonetheless dances dangerously close to buying into the false dichotomy that suggests that alternative medicine is anywhere in the same ballpark as science-based medicine, or, as I sometimes refer to it, the fallacy of false balance. Regular readers will likely recognize one of the “experts” quoted in the article. Readers of the HuffPo article I just cited will recognize the other one as the woo-friendly doc cited in that very article, Aditi Nerurkar, MD, Assistant Medical Director at the Cheng and Tsui Center for Integrative Care at Beth Israel Deaconess Medical Center in Boston. Dr. Nerurkar, it turns out, is a true believer. She openly admits that the evidence base for CAM, in particular mind-body therapies, is very weak, but really, really believes that they are effective anyway:
At Beth Israel Deaconess, for instance, Nerurkar uses CAM techniques, such as yoga and meditation, in conjunction with standard drugs and procedures in internal medicine. That combination is now being called “integrative medicine.” But Nerurkar has good reason for keeping her enthusiasm for CAM in check. “Some of these treatments have evidence supporting them, and some don’t yet,” she admits. Nerurkar acknowledges there are still many gaps in knowledge of mind/body treatments, and they will have to be filled in with further studies, but she strongly believes those future studies will show effectiveness.
It’s all well and good to believe that a treatment will one day be validated in clinical trials. There’s nothing wrong with that. However, in that case, you have to admit that such treatments have to be considered experimental and therefore shouldn’t in general be used outside of the context of well-designed clinical trials. Would Dr. Nerurkar use an unapproved drug outside of a clinical trial? I wouldn’t, but that’s what CAM practitioners do with CAM all the time. Their philosophy seems to be just to keep using it and hope like hell that clinical trials eventually validate it. The problem is, from the standpoint of scientific plausibility, many CAM studies are incredibly implausible and therefore highly unlikely ever to be validated. However, it is that same “noise” in randomized clinical trials of treatments with low plausibility that keep a steady trickle of seemingly positive studies that are the result of chance, confounding factors that weren’t adequately controlled for, or bias.
Unfortunately, compared to 30 years ago, things have almost completely flipped. In the past, the practice of medicine was presumed to be based on science and clinical trials. Now, that standard no longer exists:
CAM became complicated for doctors in the 1980s, when the American Medical Association (AMA) was forced to abandon a simple rule: The medical profession should have nothing to do with alternative medicine. For 30 years, Section 3 of the AMA principles of medical ethics stated, “A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle.”
The AMA expunged this principle after it was sued for antitrust violations by chiropractor Chester A. Wilk in 1976. The AMA litigated for 14 years and ultimately lost the case.
Of course, the AMA is not the be-all and end-all of medicine. Less than 25% of physicians belong to the organization anymore the last time I checked. However, over the next 20 years, we saw the Dietary Supplement Health and Education Act (DSHEA) of 1994, the formation of NCCAM, and the infiltration of scientific medicine with pseudoscience, culminating in our current state of affairs. And here’s where the article goes astray at the end. After the criticism of CAM as unscientific, the article closes with the observation that failure to inform patients about CAM treatments could result in a malpractice suit. Only a few short years ago, I would have considered this utter nonsense, but now I’m not so sure:
Are doctors legally required to discuss CAM treatments with patients? The jury is still out on that.
Attorneys who have dealt with lawsuits involving CAM have differing opinions. Ericka L. Adler, JD, a partner in the Chicago law firm of Kamensky Rubinstein Hochman & Delott, which handles healthcare cases, says that doctors can tell patients, “I’m not familiar with these other types of products,” and leave it at that.
Others feel that the law of informed consent requires physicians to discuss CAM treatment options. “The information about potential risks, including frequent, nonserious adverse effects as well as serious complications, is crucial for patients to know. Failure to disclose availability of benefits and risks of CAM treatments could give rise to malpractice claims,” according to Edzard Ernst, MD, and Michael Cohen, JD.
That is, of course, the message that CAMsters have been relentlessly parroting for the last few years, namely the claim that CAM is effective and therefore not informing patients about it is a violation of informed consent. The idea, of course, is to legitimize CAM and try to get doctors to “learn about CAM” in a credulous manner, the better to spread that credulous thinking to their patients and even refer patients to CAM practitioners. I still think it’s nonsense. Physicians shouldn’t be obligated to “inform” patients about pseudoscience other than to tell them it’s pseudoscience and quackery. Certainly, that’s what I do whenever a patient asks me about specific CAM modalities with which I’m familiar. I do not, however, bring it up myself. The patient has to do so before I will comment.
Now, the part that’s the failure is the very end, where the reporter concludes by extensively quoting Dr. Nerurkar, who basically says the same thing she said in the HuffPo article about how she thinks that patients should be referred for CAM earlier in the process. Sadly, I fear that this particular article ended up falling into the same trap of false balance. The overall impression left after reading this article is that CAM is ascendent, that there are some skeptics (including a token skeptic), but the evidence base is rising to the point that it might even be a lapse in informed consent if a physician doesn’t suggest CAM as a treatment.
Maybe woo is ascendent, after all. The bait and switch works.
37 replies on “Alternative medicine: The bait and switch is working”
As far as I know, the A.M.A. still has in its code of ethics a proscription against physicians selling remedies not shown to be effective:
“Physicians who choose to sell health-related products from their offices should not sell any health-related products whose claims of benefit lack scientific validity. When judging the efficacy of a product, physicians should rely on peer-reviewed literature and other unbiased scientific sources that review evidence in a sound, systematic, and reliable fashion.”
Drat, their comments on the article are closed. Nothing like some Huffpo Hand-to-Hand combat in the morning, especially if I have a bottle of Melbourne Old and Yellow* at hand to swing at ’em.
Oh, and it’s “Schocker”, by the way. I know you hate typo corrections, but as one who has an often-mangled name, I tend to notice these things.
Being in one of my more misanthropic moods, I’m coming to conclusion, that CAM is not the health service we need, but is a health service we deserve. There are times I am starting to think, we should let the quacks have free reign and wait till their whole client base dies out due to lack of proper medical care. Then maybe, and only maybe, we (as the Humanity) will deserve SBM medicine for all.
There’s a time and place for everything, but as far as medicinal treatment goes it shouldn’t really include CAM. But ultimately if the patient is happy, let it be.
DB @1: Unfortunately, doctors who aren’t in the AMA (meaning about 3/4 of US doctors, according to Orac) are not necessarily bound by the AMA’s ethics code. Furthermore, nothing in that statement prohibits doctors from recommending such products the way they prescribe drugs (except that, unlike prescribed drugs, no paperwork is necessary). In any case, I have yet to encounter a non-woo practitioner who sells remedies from her office.
palindrom @2: I’m not familiar with that sketch, but I’d guess that Melbourne Old and Yellow is made of something other than fermented grape juice. Something that would make it ideal for hand-to-hand combat.
“Physicians shouldn’t be obligated to “inform” patients about pseudoscience other than to tell them it’s pseudoscience and quackery.”
Couldn’t agree more. I am an endocrinologist, and we seem to attract a lot of pseudoscience especially in the realm of “natural” hormone replacement. I make a point of staying up (to the extent that I can, given the difficulty of finding reliable information on many supplements etc) on things my patients might be using, and ask about supplement use. But I don’t bring up or recommend any supplements, although I will give my opinion if asked, or if I find they are on something that is potentially harmful (e.g. patients with thyroid disease taking supplements with iodine, which potentially can worsen many forms of thyroid disease).
I’m still trying to figure out how CAM “practitioners” can convince folks that doctors don’t prescribe “diet and exercise” as part of their regular practice. I get discussions of those in almost every visit, even when the issue isn’t obviously related to food or weight, if for no other reason than to rule them out as possible causes. I guess either the CAM marks are visiting some pretty dire physicians or they’re not paying attention when they visit good ones.
#7–I think they believe physicians don’t prescribe exercise and diet because many of them aren’t sick-they are “worried well.”
Traditional cookie please….
“This is not a wine for drinking. This is a wine for laying down, and avoiding.”
JGC, isn’t that Nuit St. Wags Waga?
Damn autocorrect. Nuit St. Waga Waga…
I’m sorry to bring this up here, but I can’t find any place on your site for posting or emailing questions/comments about malfunctions on the site.
I think you have a bad script on your page. Or maybe just way too many scripts? It’s been taking three to five minutes for your page to load. It completely ties up my computer while loading. Then it takes another three to five minutes for the tab to close, during which I can’t use the computer for anything else. Windows Task Manager shows that loading your site eats up 200 to 300 MB of memory.
Today I used Ad Block Plus to block three or four dozen scripts and third-party items it sees on your site and now I can load and unload the site quickly. Of course, I don’t know which blocked item solved the problem! Sorry about that.
(Six-year-old computer with 1 GB RAM, Windows XP Pro, Firefox browser)
@ #3 The Smith of Lie; I definitely like the way you think
(hilarious AND it might work).
I’m a cancer patient and get all my care at a teaching hospital. Recently I’ve been advised by two of the doctors there to get acupuncture — one referral for headaches, one for fatigue. The cause of the headaches and fatigue are a combination of the cancer and chemo.
I respect these doctors, and I think the recommendation is essentially a compassionate attempt to use a placebo treatment. If I were a doctor I might heave a sigh of relief if a patient reported good results. But wow, it floored me. It shakes my confidence in them. If they actually believe in what they’re recommending, I can’t see how they can be competent. And if they don’t believe in it yet recommend it, I have to question their honesty in all that they say to me.
I’m a grown-up. I reported the headaches and fatigue when they asked me how it’s going. I know there’s no easy fix and I can live with that. I feel like I entered the room expecting to have an adult conversation and the doctor handed me a teddy bear — it’s incongruous and inappropriate and unprofessional.
“It shakes my confidence in them. If they actually believe in what they’re recommending, I can’t see how they can be competent. And if they don’t believe in it yet recommend it, I have to question their honesty in all that they say to me. ”
Yes, this exactly. I went to Stanford Urgent Care a few years ago when I had injured my back. The doctor told me it was just some mild soft tissue damage, something that would be self-repairing if I took it easy and used ice and NSAIDs to keep the inflammation down. That was fine, but then he starts pushing acupuncture, and trying to get me to see this one particular guy who ‘studied in China.’ Well, so effing what? Either this doc is impossibly credulous, or he’s trying to bilk patients to help his friend make money. Either way, I was really disappointed and upset.
Have you mentioned your thoughts to the docs? They might appreciate the conversation.
ABP reports 41 out of 59 items blocked for me, but 30 of those are Gravatar.
Yes, I talked with my oncologist’s PA about it. And I thrust a six-page Nonsense Treatise which had been posted on a cancer support site I frequent to illustrate the quackery that’s being thrust on the patients there (the PA had recommended the site to me, and I think she wasn’t aware it had been taken over). She was pretty astonished and it was clear other patients had been talking about the ND behind the nonsense without conveying the details about how ridiculous her treatments are.
The second time around the subject was fatigue and it was via email — I was not only tired, but very cranky! I spent three days biting the guy’s head off but not hitting Send, and finally settled with Just Saying “No.” LOL.
I’d wager that the majority of physicians are not particularly well-informed about the depth of the woo and tend toward the shruggie mentality. Talking with them about the subject if they bring it up may help educate them…just take deep breaths before doing so. 😉
Am I missing something here? Seems like some of the CAM referred to isn’t being used as quack med, but just a constructive activity to have the patient generally feel better and relieve their symptoms somewhat.
Yoga, meditation and such are not medicine, but they probably have effects on one’s health. They may be ways to offset at least two destructive influences most people live with: too much time sitting, and not enough time of calm, without rush, without worry.
What we call “exercise” is in great part a replacement for the normal exertions required of most people until the last century. Mediation of one sort or another was part of most religions, and perhaps offsets the always-on life which was uncommon though not improssible before electricity.
Something may not be a cure or treatment for any particular disease but can still be good for you, examples being obvious enough for the readership here.
yes. You’re missing the fact the the things referred aren’t “part of the CAM”. Diet and exercise are normal medicine.
You make a good point. A year ago I thought I knew enough about what “alt” med involved. I didn’t get excited about it. Then I got targeted as a cancer patient and was absolutely flabbergasted by the number of really dangerous things that are promoted, and the aggressiveness of the promotion. The PA seemed very surprised by it, too. I used to think it was the only the occasional chump who would get hurt by it. Now I’m watching people get hurt, and it troubles me, to say the least.
(Thanks for listening.)
Neither of them is a wine for drinking, @sheepmilker. They’re wines for laying down and avoiding. Bit like CAM, really.
@7: I don’t know if I’ve been visiting partuicularly dire physicians over the years, but Iv’e rarely been asked about diet or exercise.
(Once in my teens, when convalescing from a broken arm, a doctor told me that normally she’d prescribe physical therapy, but she wouldn’t this time because I was a young physically active person. I’ve always wished I’d asked her how she knew – she certainly hadn’t asked me how active I was.)
Regarding the prospect of lawsuits against doctors for not giving patients information on alternative treatments, the only scenario that would seem at all likely would be if the suit was used as a de facto way to retaliate against those who were in fact openly critical of a treatment. Otherwise, there would be no practical basis for choosing to sue one doctor over any other. I would further predict that efforts on this line would ultimately bring the same kind of backlash caused by legislative efforts to introduce creationism/ “intelligent design” in school curricula (which I can attest includes opposition from other creationists). The ultimate overarching principle would be a line I sometimes suggest applying to litigation and legislation for the disabled: “If you had to fight your way in, it’s time to get out.”
Slightly off topic, do you all know that there is a ‘board certification” in naturopathic oncology?
this is what they offer:
*Working with you to understand your goals and how to achieve them
*Treating your condition, onsite, at the clinic
*Helping people get the best treatment using all aspects of integrative care including allopathic and naturopathic medicine as well as other types of treatments
*Aiding entrance to the most progressive, modern clinical trials
*Assisting you in continuing your current treatment protocol while providing ways to minimize the side effects of conventional treatment such as chemotherapy and radiation
*Researching your options and providing you with a document prepared specifically for you
• Helping to integrate all of your physicians
*Making off-site visits when requested
I just noticed an interesting fallacy underlying the whole naturopathic movement and CAM, as far as they work under auspices of “only natural is good”. Well, what I mean is not really an independent fallacy itself, more of colorrary to our old Natural Fallacy.
So, if anything that is natural is preferrable over the malicious and laden with evil human made, why should any invervention happen at all? Disease IS natural, so it should be left alone to run its course.
Also I have a quick list of things in my sight that are clearly unnatural: PC, clothing, buildings, cars, roads, money. Can someone explain to me again why aren’t all those “nature knows what is best for you” folks ain’t running naked in the wilds instead of pushing their quackery?
This could actually be a good cure for natural fallacy – leaving a subject for a week or two with only nature one’s natural attributes to fend for himself. Provided subject survives.
Gah, double negative there. Ignore one of the negations please.
This is what I get for trying to post and work at the same time…
If CAM were being offered simply as a something to keep you constructively occupied while your disease runs it’s course, sure. But this is rarely the case. Instead CAM is being offered as a form of effective therapy–something that has the peotential to cause actual physiological changes resulting in health benefits (e.g., acupuncture offered Yodelady above to relieve headache and reduce fatigue).
co-opt perfectly science-based modalities like diet, nutrition, and exercise as being somehow “alternative.”
There seems to be some serious disagreements on what constitutes useful nutrition. It is a fact that CAM often draws upon disused portions of current and older literature, all the while suffering that “quack” attack. Disused does not equate as wrong.
… philosophy seems to be just to keep using it and hope like hell that clinical trials eventually validate it
Nah, apparently many drs quit waiting the tooth fairy at an earlier age than others.
…from the standpoint of scientific plausibility, many CAM studies are incredibly implausible and therefore highly unlikely ever to be validated
Some CAM studies/observations may contradict commercial or institutional positions and other cognitive challenges.
Between whom? Do you have some examples of “serious disagreements” about recommended nutrition between reputable authorities? I know there are serious disagreements between the various CAM proponents who make ridiculous claims for various diets, all of which work, if they work at all, by reducing calorific intake.
Sometimes CAM picks up on treatments that were abandoned for good reason, and doesn’t bother to investigate negative reports. Very often I have seen CAM proponents choose a position and then cherry-pick every study they can find that supports that position, ignoring any that do not. They fail to understand you need to look at the literature as a whole, at the quality of different studies, what confounders may have affected the results, and also understand that negative results may not have been published. They also often fail to look at pharmacokinetics, in that the doses of a drug required to maintain therapeutic blood levels are impractical or intolerable.
Sometimes a PubMed search can be illuminating; search for a treatment modality and the condition you are interested in, then look at the oldest citation and work your way forwards in time. Often you will see promising in vitro studies then animal studies, then a small human trial and then nothing – phenylacetate for cancer is a good example. That strongly suggests that either the results of the small human trial were disappointing (which means you should look more closely at it) or that another unpublished study was disappointing. Scientific researchers (and pharmaceutical companies) rarely abandon a promising line of research for no reason.
I hate to disillusion you, but the tooth fairy never came – it was your parents.
Can you give any documented examples of a safe and effective treatment that was suppressed or abandoned because of “commercial or institutional positions” or indeed due to “cognitive challenges”? Just one, perhaps?
And now for something a bit personal and perhaps slightly topic.
In a way, learning more about science-based medicine and CAM hasn’t made me happier, quite the opposite. When I was younger and got a cold, I knew exactly what to do – high doses of vitamin C with rutin, garlic, echinacea. And I felt that I was doing something to get better quicker. Now I know it does not work, so I take some pills to ease the symptoms if they get too bad and generally wait for the cold to resolve on its own. I save some money but in a way I feel helpless.
Gives some truth to the saying “Ignorance is bliss”, doesn’t it?
@ Todd W.
Yup. But at least now I know enough to turn down all of my mother-in-law’s crazy
Ups, I hit “Submit Comment” by mistake. I wanted to say “I know enought to tur down all of my mother-in-law’s crazy wooish ideas to cure all ills (including variety of supplements that “really helped her friend”, a chiro and homeopathy).
BTW, I also had to turn off a lot of scripts on the site, otherwise it would work really slowly on my oldish computer (have to buy a new one sometime these holidays).
K, sounds a little grumpy today.
prn: There seems to be some serious disagreements on what constitutes useful nutrition.
Krebz: …Do you have some examples of “serious disagreements” about recommended nutrition between reputable authorities?
Richard K Bernstein’s low carb approach to diabetes for the past 30-40 years. Of course he’s really just a ChE that got the MD for disguise to sneak into the country club’s printed adverts shop. I’ve mentioned Burton Berkson, PhD-MD before.
diets…all of which work, if they work at all, by reducing calorific intake.
uh, K I don’t know why you’re serving up such a soft example. Ketogenic diets like Atkins work by incomplete metabolism of fats.
CAM…doesn’t bother to investigate negative reports.
Actually some do. Like failures of regular medicine and captive/compromised research too :>. Btw, Mercola changed his tune on high dose vitamin A in a fairly short time span after negative reports.
CAM proponents choose a position and then cherry-pick every study they can find that supports that position, ignoring any that do not. They fail to understand you need to look at the literature as a whole, at the quality of different studies, what confounders may have affected the results, and also understand that negative results may not have been published.
I could agree that some CAM providers might fit that view, and many regular MDs too. However, CAM priorities and methodologies on quality and utility on selecting papers often may not philosophically compatible with [heap] Big Medicine even if still physically founded.
Regular medicine frequently turns a blind eye to its own favorite confounders by the handful when it comes to nutritional substance tests. Some confounders are so painfully obvious that it is hard to not reflexively discredit the regular medical believers that promote them.
…doses of a [CAM] drug required to maintain therapeutic blood levels are impractical or intolerable
Sez you. There used to be such a thing in the industrial world as “know how”. Essentially “tricks of the trade” or trade secrets of how to do things not generally recognized by beginners, journeymen or even supposed “experts”. Same thing on CAM nutrition, and MDs usually seem to be at the bottom of the class on field implemention. In nutrition, one can use knowledge of other deficiencies to turn a treatment with solid benefit into a toxic disaster by allowing the deficinecies or a specific situation to go unaddressed.
That strongly suggests that either the results of the small human trial were disappointing (which means you should look more closely at it) or that another unpublished study was disappointing.
I am more of the school of specific design, investigate all the problem areas until you can make something run well. Not this mere “lick and a promise, it doesn’t work” mime. Often failed applications reflect the person more than an early technology’s validity.
Scientific researchers (and pharmaceutical companies)
rarely abandon a promising line of research for no reason.
Your “promising” seems to refer to commercial potential for a seller, not technical superiority based on user results.
One of the things I strongly question is this presumed “efficient market hypothesis” that “if xxxx were so good the pharmas/doctors would patent/use it”. This is simply contrary to my life experience in other fields too. Can’t underestimate cupidity and stupidity.
I hate to disillusion you, but the tooth fairy never came – it was your parents.
ROFLOL, a “yo mama” insult. pffft
Can you give any documented examples of a safe and effective treatment that was suppressed or abandoned because of “commercial or institutional positions” or indeed due to “cognitive challenges”? Just one, perhaps?
Since “safe and effective” is FDA parlance for achieving a formal status these days, that is loading the die on treatments abandoned before FDA approval. For nonlegal terms, Coley’s fluid [sterile version], UFT and cimetidine might satisfy other people.