Sep 21 2011

Some Encouraging Backlash Against Nonsense

One of the themes of SBM is that modern health care should be based upon solid scientific ground. Interventions should be based on a risk vs benefit analysis using the best available scientific evidence (clinical and basic science).

As an extension of this, the standard of care needs to be a science-based standard. Science is (or at least should be) objective and transparent, and without such standards there is no way to have meaningful quality control. Without the filter of science there is no limit to the nonsense and magical thinking that can flow into the health care system. Increasingly we cannot afford the waste of fanciful and ineffective interventions, and even if limited resources were not an issue – individual patients deserve better.

It is for these reasons that we oppose the attempts by proponents of so-called complementary and alternative medicine (CAM) to erode or eliminate the science-based standard of care in medicine. Proponents differ mostly on how open they are about this goal, but there is no escaping the reality that at the heart of the very concept of CAM is at least a double standard – one in which the science-based bar for inclusion is lowered for some favored modalities.

Proponents will sometimes argue (against all evidence) that this is not the case but rather that there is prejudice and closed-mindedness against certain types of treatments. This is reminiscent of the claims by proponents of creationism/intelligent design that their beliefs are unfairly treated by scientists and school systems. In fact both cultural movements use the same language and tactics to promote their ideology against the defenders of a science-based standard -the “academic freedom” and “health-care freedom” strategies are two sides of the same coin.

Our primary mechanism for opposing the weakening of the science-based standard in medicine is simply to point to the rhetoric and tactics of the CAM proponents themselves. While they largely operate below the radar, when the light is shone on what they are actually doing the “shruggie” masses sometimes take notice. This occurred recently in Ontario, and provides an excellent example of all that I described above.

The conflict is about the College of Physicians and Surgeons of Ontario’s (CPSO) draft guidelines on Non-Allopathic (Non-Conventional) Therapies in Medical Practice. The first clue that these guidelines are likely to be problematic is in the title – the word “allopathic” is only used by CAM proponents. The term was coined by Samuel Hahnemann, the inventor of homeopathy, to refer to the conventional medicine of his day – prior to the incorporation of scientific methods into medicine. It does not reflect the philosophy or practice of modern medicine, and it is a pejorative term.

The guidelines also assume that “non-conventional therapies” should be incorporated into medical practice. Shouldn’t that be the real question, rather than just assuming they should be then exploring how to do so? The only justification given (the most common one given) is popularity (a fallacy deconstructed numerous times on this blog).

But that aside, here are the recommendations for how “non-conventional” therapies should be incorporated into practice:

Physicians are expected to propose both allopathic and non-allopathic therapeutic options that are clinically indicated or appropriate.

Any non-allopathic therapeutic options that physicians propose to patients must:
- have a demonstrable and reasonable connection, supported by sound clinical judgement, to the diagnosis reached;
- possess a favourable risk/benefit ratio, based on the merits of the option, the potential interactions with other treatments the patient is receiving, and other considerations the physician deems relevant;
- take into account the patient’s socio-economic status when the cost will be borne by the patient directly; and
- have a reasonable expectation of remedying or alleviating the patient’s health condition or symptoms.

Reasonable expectations of efficacy must be supported by sound evidence. The type of evidence required will depend on the nature of the therapeutic option in question, including, the risks posed to patients, and the cost of the therapy.

This superficially may sound fine, but is clearly crafted to lower the bar of scientific evidence for allowing “non-allopathic” treatments into medical practice. The guidelines stress “clinical judgment” rather than evidence-based standards. Further, the only time “sound evidence” is mentioned, it is immediately watered down by qualifying that the type of evidence will depend on the modality in question. Why is that?

The purpose of this language is to allow things like pragmatic studies (unblinded, uncontrolled studies) to serve as evidence for efficacy, something for which they are not designed. This is the sort of thing CAM proponents have been constantly calling for. Andrew Weil has advocated the inclusion of what he calls “uncontrolled clinical observation,” or what has traditional been called “anecdotal evidence.” David Katz from Yale’s Integrative Medicine program has called for “a more fluid concept of evidence.”

The evidence is absolutely clear – the CAM movement is about creating a double standard to allow in medical modalities that are not adequately science based, or to decrease the overall standard of care for medicine with healthcare freedom laws and guidelines that water-down what qualifies as evidence.

Fortunately there has been pushback against these proposed standards. The Canadian Medical Association had this to say:

“The use of complementary and alternative medicine in Canada should be founded on sound scientific evidence as to its safety, efficacy and effectiveness: the same standard by which physicians and all other elements of the health care system should be assessed. When alternative treatment modalities do demonstrate effectiveness, they are usually incorporated into the mainstream of medicine. Therefore, one could argue that complementary and alternative therapies are by definition less demonstrably effective than conventional medical treatment.”

This is exactly correct – CAM modalities by definition have not been adequately shown to be safe and effective, else they wouldn’t be CAM. In other words – we don’t need this special category of treatment. Its only practical functions are marketing and to create a double standard.

Even worse, these standards try to muzzle science-based professionals who would criticize unscientific modalities by including a provision that “non-clinical judgement” should be avoided. This too has caused push-back:

The guidelines may be “interpreted as impressing tight limits on physicians’ ability to state their honest, scientifically sound objections to pseudo-scientific medical theories and ideas,” the Committee for the Advancement of Scientific Skepticism contended. “Their non-conventional medical counterparts feel no such compunction in spreading misinformation about legitimate medical practices such as vaccination, as well as in misrepresenting the scientific standing of dubious non-conventional practices.”

This has also been a long time strategy of the CAM movement – the use of political correctness to silence legitimate criticism. This is a strategy with which I am personally very familiar – attempts at appropriately criticizing unscientific philosophies or claims are often countered with accusations of being closed-minded, bigoted, or even on the take.

Conclusion

The proposed Ontario guidelines are a transparent attempt to water down the science-based standard of modern medicine to allow for what was once called fraud and quackery into medicine, and further to shield such quackery from appropriate science-based criticism. It is no an isolated incident, but is a primary strategy of those hoping to advance CAM into modern medicine.

It is heartening, however, to see that such attempts are now meeting some backlash. Perhaps the CAM proponents have overplayed their hand a bit and those who have been uneasy with the claims of CAM proponents have felt a little more empowered to speak up. Let’s hope this trend continues.

________________

Cross-posted at Science-Based Medicine

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21 responses so far

21 Responses to “Some Encouraging Backlash Against Nonsense”

  1. PharmD28on 21 Sep 2011 at 10:32 am

    A ubiquitous latent apathy/complacency about CAM therapies exist within the profession of pharmacy. I am a clinical pharmacist – graduated in 2007. When I speak to students, residents, colleagues, the now assistant dean at my university, other academics at times, I find myself feeling a bit like I have a “strong opinion” about CAM therapies amoung many pharmacy colleagues. I mean, really, not many of them recommend black cohosh, bilberry, supplements, etc, but when approached about CAM therapies in real life, they sort of take an apathetic stance on it and care not to simply openly call it what it is – pseudoscience.

    Also when discussing it academically with students, rarely have I heard people come out as “harsh” as the likes of Dr. Novella and other “skeptical” scientists. And indeed, now as I speak with students and residents about this topic (and believe me it comes up at least once per week in my practice in various forms), I am forced to be a proud skeptic (and demand good evidence)….the students I think are enlightened by someone making a rational evidence based stance on an issue that they were more or less agnostic about prior…but with colleagues and academics sometimes who have entrentched beliefs about CAM, placebos, etc…I feel that I have one of two choices 1) be politically correct and not actually make a rational science based argument that will be viewed as a “strong opinion” or “hard lined” or 2) make it known in a calm collective manner and hope it sinks….well it does not always sink :D

    on a side note, has anyone ever noticed that a debate with another person about CAM can somehow lead to a discussion of religion? I have in 3 seperate incidents in the last 2-3 months discussed CAM with some students, my mother, and a friend…and at the point in the conversation that they realize that my demand for good evidence to schow efficacy/safety no matter what as a good standard to have…then someone throws out the “well science cannot prove everything card” – which they then take a turn for faith and religion….is that a common occurrence fellow skeptics?? I was FLOORED when speaking with a pharmacy student when discussing EBM turned down the road of religion…talk about awkward and really? WTF?

    I find my school’s inclusion of a pro-CAM course just sad…and they lack a strong voice to state boldly and clearly that “pharmacists should not recommend unproven therapies (CAM)” …..the assistant dean does not sympathize really…I am thinking about doing some polling of graduating pharmacy students or something like that to see if I can get a feel for how recent graduates stand on CAM therapies.

    It seems to me that we pharmacists should do a CAM course and discuss in detail the EBM that is associated with CAM, rather than doing a dogmatic CAM course….

  2. PharmD28on 21 Sep 2011 at 11:17 am

    Anyway, blah blah blah, my disorganized nearly incoherent blatherings are supposed to depict within my area of practice that I have noticed the same “uneasiness” that you speak of Dr. Novella and I too hope that it continues to trend away from “uneasiness” to rational unapologetic science based criticism – to strip away its someone privealaged status from science….

  3. Enzoon 21 Sep 2011 at 11:43 am

    It seems to me that we pharmacists should do a CAM course and discuss in detail the EBM that is associated with CAM”

    — PharmD28

    Couldn’t agree more. Any health care worker should be educated in CAM from the perspective of SBM. I find it is extremely useful when getting into the alt. med argument to know what you will be up against. The only way to even make a dent in someone’s opinion about CAM is to really be able to speak clearly and calmly about the facts with examples to which you can direct them. Sadly, I don’t think you will find many people willing to teach this kind of thing in an academic setting.

    Anyway, it’s good to see that a body of physicians is wise and careful enough to combat guidelines like this.

    And just to vent, NPR had a discussion on aggressive cancer treatment not long ago (podcast available). A caller described her abandoning medicine for herbs and homeopathy (!) and the physician guest on the show failed to comment about that aspect — that’s a big part of the problem.

  4. Gehackteon 21 Sep 2011 at 12:07 pm

    It’s bizarre in a way since we have the government healthcare, that they would even want to dabble in the new age, because it costs the gov. money. Either by allowing doctors to waste time on it, or by delaying better treatments and costing more because they got worse.

    Healthcare as usual is a big debate in the upcoming Oct Provincial election. I guess I’ll have to re-read all the platforms if this is leaking into it.

    As always though, between a rock and crazy place… Dang hippies.

  5. PharmD28on 21 Sep 2011 at 2:53 pm

    “Sadly, I don’t think you will find many people willing to teach this kind of thing in an academic setting.”

    Hmm…that is curious..although if they mandate having basically a CAM proponent teach it to students without SBM approach, then that seems increadibly wrong…and it does take its toll on perpetuating the belief that CAM while not helping most, hey, maybe it will help a few people here and there, who knows? I see this in my pharmacy colleagues at times…just last week I was speaking with a student about a 23 pill supplement/herb regimen and how crazy it was…another pharmD chimed in “yeah, I had a preceptor in school that took a regimen like that”…I thought for a second that she was going to agree with me, and I went on to laugh about it and basically call someone like that a moron (woops :D ) – I mean 22 pills with no evidence??!! Well, that was a mistake apparently because then my colleague got to telling me she was very healthy and that “it worked for her”…and suddenly I was an instigator, a provocateur, with a “strong opinion”. Then the colleague went on some basic “well EBM cannot do everything” rant, then also went on to explain that we cannot explain the placebo effect….if the conversation had gone any further we would have been taking about faith and prayer for medicine….luckily it didnt.

    Regarding NPR…I am an avid listener, but their health reporting as far as I can remember is not stellar always…last month they pretty much did a drug advertisement for pradaxa – did not really get the point that piece…it was pretty much a DTC ad and added nothing more….they do a great job though in bringing up good vaccine reporting consistently…that I very much appreciate….

  6. Kawarthajonon 21 Sep 2011 at 3:02 pm

    There are a few disturbing points I’d like to make about this story.

    First of all, the initiative to include these guidelines came from the College of Physicians and Surgeons of Ontario – correct me if I’m wrong, but this is an organization run by physicians, right??? It does not seem, as Steve has suggested in his post, that this initiative came from CAM – it came directly from physicians. It is an outrage that physicians would propose such a debasement of scientific rigor in their practice.

    The second issue comes from the quote that Steve used in his post, which starts “Physicians are expected to propose both allopathic and non-allopathic therapeutic options that are clinically indicated or appropriate.” They are EXPECTED to propose both “allopathic” and “non-allopathic” treatments??? Does this mean that (if these proposals are accepted) a physician can be disciplined by the College for not proposing that a patient seek out both proven, medical and unproven, non-medical treatments?

    Another issue is raised by reading the proposed guidelines that Steve included a link for. The policy makes it sound like a lot of physicians are already using CAM in their practice and that these guidelines are a response to that ever increasing trend. I, for one, would be very concerned if my doctor gave me a homeopathic treatment instead of a SBM treatment!

    I’m glad that the OMA took such a strong stance against these proposed guidelines, but they don’t have any say in the matter, since it is up to the board of the CPSO to decide on these policies in the long run.

  7. PharmD28on 21 Sep 2011 at 4:16 pm

    “Physicians are expected to propose both allopathic and non-allopathic therapeutic options that are clinically indicated or appropriate.”

    …”that are clinically indicated or appropriate.”

    How are MD’s, pharmacists, PA’s, etc…supposed to find what CAM therapy is indicated for what? And based on what? Is there an allopathic consensus guideline that we can all look to to see what the consensus for these therapies are? An MD at my work recently went to some sort of CAM conference I believe…would be interesting how they instruct MD’s desirous to learn how they should use CAM therapies?

  8. nybgruson 21 Sep 2011 at 6:58 pm

    @PharmD28:

    I feel your pain brother (or sister). I am pretty much always the strident one. The one that makes the waves. I’ve been told some people are afraid to comment since they know I will often have some scientific rebuttal. And it amazes me that people studying to be physicians are afraid to have their views challenged by science so they stay quiet and go on believing whatever the hell they want to believe. Dr. Novella said it best some years back:

    Standards are being sacrificed at the altar of equality

    It is faux-pas these days to tell someone they are wrong. People identify with their ideas and beliefs so much so that they cannot separate them from their identity. Telling someone that a 23 pill regimen is BS is telling them that they are BS. And yes, I find that it does often devolve into discussion of religion. I have been very avid in my study of all these topics over the past couple of years and I can see very distinct and clear parallels between religious thought and CAM apologetics.

    But I decided that I will not aqcuiesce. If I have the science to back me up I will stand strong. If that loses me “friends” so be it. If it makes me someone think I am a prick – so be it. I make it a point to state that I am not attacking the person, just the notion, though that rarely helps.

    Yet every once in a while, I do have to step back. I sometimes feel like I may be getting radicalized and losing focus and understanding and that I may be wrong. When a dozen people say you are wrong and that reflexology and acupuncture are OK to recommend to patients, it makes you wonder. So I learn more and study harder and thankfully I have a few friends and colleagues who are like minded and give me some perspective.

    But we need more pharmacists like you. So keep up the strong stance and help try and make people realize it is insane to be OK with providing unproven and disproven treatments “just cuz it might maybe help a little in some cases and, well, science doesn’t know everything!

  9. robmon 21 Sep 2011 at 11:29 pm

    This story reminded me of an anecdote Steve tells on the SGU about convincing some of the faculty at Yale:

    I pushed the issue, however, until we actually cracked open a syllabus and read what was going to be taught by the “integrative” physician who was going to teach that class. The relevant physician read quietly for about ten minutes while the rest of us continued to chat. He then looked up, a bit stunned and even outraged, and said, “This is all nonsense.”

    Also available here:

    http://theness.com/neurologicablog/index.php/follow-up-on-atlantic-article/#more-3356

    I take the CMA’s response as a hopeful sign about about just how far cam can actually get when it actually tries to get integrated into real medicine. Sadly to few doctors stand up to it until something like this happens and remain whats the harm shruggies.

  10. eiskrystalon 22 Sep 2011 at 3:57 am

    take into account the patient’s socio-economic status when the cost will be borne by the patient directly;

    I am reminded of the situation some years back in China being told that it was basically western medicine for those who could afford it and chinese medicine for those that couldn’t.

    Given the state of the economy, this innocent little statement could be your biggest problem. There isn’t much that’s cheaper than tap water, fridge magnets or waving your arms about.

  11. PharmD28on 22 Sep 2011 at 9:27 am

    @Nybgrus

    Thanks, I needed that bit of encouragement! PS, I am a “brother” – well, that is to say I am a male, lol…

  12. tmac57on 22 Sep 2011 at 10:11 am

    Maybe SBM should consider a reverse strategy. Start demanding a HIGHER level of evidence for CAM than for SBM,based on it’s low level of plausibility. Then when the expected cry comes up from the CAM world,then say “So you think that it is unfair to hold CAM to a different standard than SBM?Okay,you win,let’s have the same standard for both then”

  13. PharmD28on 22 Sep 2011 at 12:24 pm

    tmac57…lol…I like that…but that whole line of thinking makes total sense – its like Dr. Oz told Steve in that interview..something to the degree of “why is it that science cannot get its arms around alternative medicine” …..apparently we are using the entire incorrect line of thinking…we have to define uncontrolled observations as better predictors of efficacy and safety….our whole way of thinking is just too “black and white”…..interesting a colleague blamed me just last week of being too “black and white” – similarly Dr. Oz called steve “dismissive” (even though his conclusion was made based on alot of consideration)….and my all time favorite 1 month ago we were having dinner with some co-workers and a pharmacy student, after I kept pointing out that this given CAM therapy had no evidence to support efficacy/safety…she claimed that “well, you are just bias”….lol

    thats it, we are bias…our realities are not immutable – uncontrolled observations are no problem – if millions do it there must be something there…and there is a god that will help me in the process…take that science based medicine :D

  14. TylerRon 22 Sep 2011 at 1:05 pm

    I took a computer course in high school and I’ll never forget the first thing the teacher said to us:

    “Who here is good with a computer?”
    *I, amongst a few others, raise my hand proudly*
    “Uh huh, good, good.”
    *She writes down our names*
    “I am not worried in the slightest about those of you who didn’t raise your hands. It’s the ones who think they know about computers that actually know just enough to break and ruin all my stuff, you’re the ones I am worried about”
    *She holds up the list and points at us*
    “I’ll be happy so long as you computer-types don’t ever assume you know what you are doing to my equipment.”

    CAM seems to be a similar problem, by which it is caused not so much by the experts themselves, but rather by those in the surrounding them: nurses, pharmacists, therapists, etc. They know just enough to sound legit and successfully peddle their ignorance to the public. Many of them also know enough to sound like they are actually making/holding a point in an argument, again to the views of the public. I get trapped having to explain the basics of science, which I am not going to do at all in a twenty minute conversation, while they get away with “allopathic medicine focuses on the symptoms, not the person”, and it’s embarrassing to see how many people nod their head in agreement. About the only effective argument I can make in that small a time in the challenge “Name one non-allopathic anything that has ever cured a disease.”

    tmac57: It is my understanding that is the strategy that is being used against CAM-proponents, but I don’t know if I’ve seen much fruition from it. Ultimately, is it too difficult to stop bureaucracy once it starts, or is the (profitable) industry propping itself up with lobbyists? I suspect it’s a mixture of those.

  15. steve12on 22 Sep 2011 at 1:12 pm

    “Maybe SBM should consider a reverse strategy. Start demanding a HIGHER level of evidence for CAM than for SBM,based on it’s low level of plausibility. ”

    I know that you were speaking strategically, but from a Bayesian POV (and this is where a lot of stats/scientific reasoning is going) this is precisely what should be done.

    Unlikely mechanisms mean a less likely prior. That’s just common sense. To literally swing it around 180 degrees is beyond irrational.

  16. tmac57on 22 Sep 2011 at 4:51 pm

    steve12-Yeah,I thought about that too,and CAM should be held to a high level of evidence in the case of say homeopathy,where the plausibility is basically nil. But at this stage of the game when the tide is going the other way,getting them back to even sounds like a win.

  17. nybgruson 22 Sep 2011 at 4:55 pm

    @ PharmD28:

    We all need the encouragement. It really does suck to be the lonely skeptic in the room. Another reason I see a parallel between CAM and religion is because in both, when you point out the science of why they cannot be right, the answer is “Why are you trying to take that away from me?” with those doleful eyes hinting at a sniffle.

    As for the brother/sister thing – I just wanted to make sure… I hate making sexist assumptions, especially considering the the most awesome PharmD I have ever known (and PI on my mol pharm post-grad research) was a woman (and a stunningly beautiful one at that).

    @TylerR:

    Very good point indeed. The Dunning-Kruger effect is keeping a lot of bullshit afloat. But do realize that it is also very much phsyicians that are part of it as well. I’d reckon you are right that it is probably moreso the ancillary staff as you say, but the effect from doctors is not to be discounted in the slightest.

  18. TylerRon 22 Sep 2011 at 5:54 pm

    nybgrus: I’d like to see numbers on that, as well. My view on it is influenced by the nurses and midwives I know (btw, the more pseudoscience midwives incorporate, the more money they make; just my observation), as well as the reports on therapeutic touch, etc. Here in Texas I do find a lot of woo peddlers, but they’re usually in chiropractic or the sports-medicine-type physical therapy. It could very well be that I do not personally know too many physicians. I remember Dr. Novella bringing up on SGU a few times about the education that medical personnel receive regarding scientific methodology, and I believe that’s why he formed SBM.

    Now you got me really pumped to look at a report that doesn’t exist. I’d like to see the belief/peddling of [pick your pseudoscience] correlated to nurses, physical therapists, and physicians. Well… I’d like to see a lot of reports.

  19. nybgruson 22 Sep 2011 at 6:48 pm

    @TylerR:

    I agree. I would very much like to see such numbers. That is why I left my comment as qualitative. But I would posit that 1 physician endorsing woo is worth quite a few nurses endorsing it as well. They simply have much more authority and the perception that they are more educated thus their opinion should count for more. Which is true indeed, but very selectively applied in favor of CAM and rarely against it. “Teach the controversy” and all.

    I know from my experience in medical school that there are indeed a lot of students coming into the program primed thinking that that CAM should be incorporated and definitely believing in the naturalistic fallacy. When they come in with these pre-conceived lay notions about CAM and that “natural is better” they frame their understanding and study during med school through that lens. It doesn’t help that we have sympathetic CAM lecturers and and an integrative medicine department to bolster those notions.

    That is why people find me annoying – I constantly try and raise awareness of this stuff and absolutely refuse to let anyone around me call exercise, diet, supplements, massage, etc “CAM” – I will literally stop the conversation and be the a$$hole that says, “No. That is entirely science based and used regularly in actual medicine.” It is the best I can do to try and do my part.

  20. PharmD28on 23 Sep 2011 at 9:43 am

    @nybrgrus and TylerR

    Yes, It would be interesting to see hard stats on how various professions are dealing with this issue. In my clinical pharmacy practice, and just my general observations with media in my area…I feel a HUGE issue are these infomercials and other ads that come on…I have had a good number of conversations from veterans who have multiple co-morbidities on say 8-12 medications…and they saw on TV some person talking with authority about this and that helping you get off all of the pills…oprah, dr. Oz, etc etc….then we have patients that come to our offices and in our pharmacies etc…many times they may not even ask a pharmacist about herbal meds…or ask their physician about it….I have worked in retail pharmacy and I almost never have someone come up to me with a bottle of an herbal med or homeopathic med and ask “does this stuff really work?” in hopes that the pharmacist will give them an informed skeptical decision based on science….many times if I do such a thing in a calm and rational way I get an evil eye (that does not stop me from trying though :D )

    Same with MD’s….they may not even mention it to the MD’s at times (isnt there polls that suggest that, I recall Dr. Oz pointing that out, that people are ashamed to bring it up with their MD’s??)…and when a physician is asking about med reconciliation and a supplement or an herbal comes up…they are time strapped and are forced to consider if they are going to spend their time discussing such an issue….they have like 20-30 minutes to do a bunch of clinical reminders, order meds, take care of immediate needs, assess the patient, order needed consults…etc…I believe that the result is, is that it falls down on the priority list….

    I would not be quick to judge one profession more than others…I think the root source of this crap is not from MD’s, nurses, or pharmacists….but from their various marketing sources and now with the internet….take food inc for example..I liked a few parts of that movie in ways, but their facebook page is a brood of deranged morons and in such spaces in the internet, the naturalistic fallacy is very strong…..and by the time this stuff falls in our lap, we are asked to, if even possible, spend enough time to turn a patient into a skeptic, or at least de-brainwash them a bit…??

  21. PharmD28on 23 Sep 2011 at 11:05 am

    “nurses, pharmacists, therapists, etc. They know just enough to sound legit and successfully peddle their ignorance to the public.”

    Ouch man, jeez….thats harsh….I would ask that such a claim be accompanied by some form of reference or something….I can only speak to my 10 years of experience within my field and pharmacists are largely very skeptical of CAM therapy and I have yet to meet one that “peddles” CAM….clearly the likes of the pharmacy chains and other chains sell the stuff, but the pharmacists that staff these pharmacies do not have anything to do what they stock on the shelf…the corporation and front store people stock that based on market forces only….

    My “criticism” of pharmacy was to point out not that they are “pro-CAM”, but rather that they are sometimes left insufficienctly anti-CAM enough – which is to say is a position of considering the SBM in that area…

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