Words like these are sure to persuade me that this chiropractic conference announcement is an invitation to abandon reason and dive into pure, unappetising BS. Reading the full text confirms my suspicion; here are a few quotes:
… Chiropractic practitioners are blazing new trails in pediatrics, neurology, neuroplasticity, and multisensory integration, pushing the understanding and possibilities of greater health potential for [autistic] children. This first-ever chiropractic pediatric CE program, with an emphasis on autism, will open the door to more chiropractors serving this precious group of children, taking the daunting fear out of this neurodevelopmental disorder and replacing it with optimism and hope.
AutismOne Online Media Director Candyce Estave said: “As a chiropractor, you’ve already displayed the courage to pursue a better way for your practice and your patients. You’ve shown your patients how supporting the healthy terrain and flow of the body underlies maintaining good health. But what about what’s called ‘autism’? How do you help the multitude of children and families who would love to seek your services for that? You can learn how at the AutismOne 2018 Conference!”
Chiropractic emphasizes the inherent recuperative power of the body to heal itself when it is free of nervous system interference and given the right conditions. Led by Steve Tullius, DC, the Chiropractic Pediatric Continuing Education Credit Program will bring together the best information from the chiropractic and other healing communities to prepare the practicing chiropractor with up-to-the-minute information, confidence, and resources to help children with autism get better. The CE program is co-sponsored by Sherman College of Chiropractic.
Dr. Jeanne Ohm, chiropractor since 1981 and director of the International Chiropractic Pediatric Association since 2002 says, “This year’s AutismOne Conference will offer essential fundamentals in caring for children with these special needs. I encourage all chiropractors to expand their practices and offer their vital services to this growing population in such dire need.”
END OF QUOTES
Blazing new trails in pediatrics, neurology, neuroplasticity, and multisensory integration?
Are they claiming that freeing autistic children from ‘nervous system interference’ (with spinal ‘adjustments’ no doubt) cures autism?
This assumption would put chiropractic firmly into the category of anti-scientific quackery. Seen from this perspective, the little footnote to the announcement is rather hilarious:
“Professionals from other scientific disciplines are also welcome to attend.”
Weleda, a leading manufacturer of homeopathic preparations, is, according to their own judgement, a ‘unique organisation – economically thriving, kind at heart and committed to the well-being of our planet, our environment and our people. We’ve grown into that role through the adoption of seven basic principles which are unchanging, binding for everyone who works with us, and which clearly underpin the way we work.’
The first of these 7 principles is the ‘Fair treatment of customers, partners and suppliers‘. Fair treatment and being ‘kind at heart’ would include telling the truth, wouldn’t it? But reading what Weleda state about homeopathy, one might wonder!
The Weleda article entitled ‘An introduction to Homeopathy’ contains many statements worthy of some critical analysis, I think. Here is a selection of 10 just quotes:
- … a [homeopathic] remedy [is] made from a natural substance… in a tiny dose which has been ‘potentised’ to be effective.
- Many people choose this approach for every-day family ailments, with a homeopathic ‘first aid kit’…
- … allopathic medicine works against the disease and its symptoms using “anti” drugs…
- Homeopathy works by stimulating the body’s own natural healing capacity.
- If you do experience complex, persistent or worrying symptoms then please seek the advice of a doctor who specialises in homeopathy.
- Today there are four homeopathic hospitals offering treatment under the National Health Service – in London, Glasgow, Liverpool and Bristol.
- Homeopathy can be used to treat the same wide range of illness as conventional medicine, and may even prove successful when all other forms of treatment have failed.
- … the fact that the remedies are widely used on animals dismisses the idea that the success of a treatment is all in the mind.
- Occasionally, symptoms become worse on first taking a homeopathic medicine. This is called an ‘aggravation’, and is a good sign that the remedy is working.
- … some homeopathic remedies will successfully treat many people with the same symptoms. For example, arnica is usually used for muscular bruising …
And here are my thoughts on these 10 statements:
- I had always thought that homeopathics can be made from any substance (including Berlin Wall) and not just natural ones. Moreover, the dose is often not ‘tiny’ but non-existent. Finally, the assumption that ‘potentisation’ renders remedies ‘effective’ is pure wishful thinking.
- A homeopathic ‘first aid kit’ is a contradiction in terms. If someone needs first aid, she surely must avoid homeopathy.
- The term ‘allopathy’ is a derogatory term created by Hahnemann to defame the heroic medicine of his time. The notion of ‘anti-drugs’ is popular in homeopathy, but evidently, it is pure nonsense.
- This notion is wishful thinking by homeopaths at its best; there is not a jot of evidence that it is true.
- If you do experience complex, persistent or worrying symptoms then please seek the advice of a doctor who practices evidence-based medicine but NOT homeopathy.
- This statement is untrue; a footnote to the article states ‘Copyright 2017 Weleda UK’, it is thus odd to see that Weleda is so ill-informed.
- The claim that homeopathy is a panacea is dangerous nonsense.
- This notion is endlessly being promoted by homeopaths. Sadly the repetition of a falsehood does not create a truth (see for instance here).
- ‘Homeopathic aggravations’ are a myth.
- Yes, homeopathic arnica is used for muscular bruising – but it not effective for that or any other indication.
It is only fair, I think, that I declare my conflicts of interest in relation to Weleda.
While at Exeter, I ran during 14 years an annual conference for researchers in alternative medicine. One year, I accepted a modest sponsorship from Weleda for this meeting [I forgot how much and which year precisely this was, possibly around 1999 and probably around £ 3 000].
More importantly, Weleda was one of the companies that financed the German journalist Claus Fritzsche who then spent much time and effort to attack and defame me. This story that ended tragically with Fritzsche’s suicide.
Needless to say that I regret both events.
Arguably, I therefore have two opposing conflicts of interest, one pro and one contra Weleda. This is why I tried to focus my comments purely on demonstrable facts. They show, I think, that Weleda’s claims about homeopathy should be take with more than a little pinch of salt – or perhaps even with a dose of NaCl, C200?
The claims that are being made for the health benefits of Chinese herbal medicine are impressive. I am not sure that there is even a single human disease that is not alleged to be curable with the use of some Chinese herbal mixture. I find this worrying because some patients might actually believe such outrageous nonsense, particularly since Chinese researchers seem to bend over backwards to support them with science… or should I say pseudoscience?
This study was aimed at evaluating the association between mortality rate and early use of Chinese herbal products (CHPs) among patients with lung cancer. The researchers conducted a retrospective cohort study based on the National Health Insurance Research Database, Taiwan Cancer Registry, and Cause of Death Data. Patients with newly diagnosed lung cancer between 2002 and 2010 were classified as either the CHP (n = 422) or the non-CHP group (n = 2828) based on whether they used CHP within 3 months after first diagnosis of lung cancer. A Cox regression model was used to examine the hazard ratio (HR) of death for propensity score (PS) matching samples.
After PS matching, average survival time of the CHP group was significantly longer than that of the non-CHP group. The adjusted HR (0.82; 95% CI: 0.73-0.92) in the CHP group was lower than the non-CHP group. Stratified by clinical cancer stages, CHP group had longer survival time in the stage 3 subgroup. When the exposure period of CHP use was changed from 3 to 6 months, results remained similar.
The authors concluded that results indicated that patients with lung cancer who used CHP within 3 months after first diagnosis had a lower hazard of death than non-CHP users, especially for stage 3 lung cancer. Further experimental studies are needed to examine the causal relationship.
I would argue the direct opposite: further studies along these lines would be a waste of time!
I can name numerous reasons for this, for example:
- Investigating CHP as though it is one entity is nonsense. There are thousands of different CHPs; some are placebos; some are toxic; and a few might even have some health effects.
- The observed effect is almost certainly an artefact; the matching of the groups might have been sub-optimal; the CHP group differed systematically from the control group, for instance, by adhering to a healthier life-style; etc, etc.
All of this should be so obvious that it hardly deserves a mention. Why then do the authors not point it out prominently and clearly? Why did they ever embark on such a fatally flawed project? I cannot be sure, of course, … but perhaps one possible answer might be that the lead author is affiliated to a Department of Chinese Medicine?
I have often remarked on the fact that, in alternative medicine, more surveys get published than in any other medical field. Typically these surveys are not just useless but overtly counter-productive:
- they tend to be of very poor quality;
- their results are not generalizable and thus meaningless;
- they show that a sizable proportion of the population uses alternative therapies, pay out of their own pocket for them, and are satisfied with them;
- the authors then state that it must be unfair that only the affluent can benefit from alternative medicine;
- eventually, the conclusion is reached that alternative medicine should be paid for by the healthcare system and be free for all at the point of usage.
Therefore, I find that it is a waste of time to even read surveys of alternative medicine usage. But every now and then, one does come along that is worth discussing – like this one, for instance.
The survey evaluated dietary supplements (DS) usage by US adults aged ≥60 y to characterize the use of DSs, determine the motivations for use, and examine the associations between the use of DSs and selected demographic, lifestyle, and health characteristics. Data from 3469 older adults aged ≥60 y from the 2011-2014 NHANES were analyzed. DSs used in the past 30 d were ascertained via an interviewer-administered questionnaire in participants’ homes. The prevalence of overall DS use and specific types of DSs were estimated. The number of DSs reported and the frequency, duration, and motivation(s) for use were assessed. Logistic regression models were constructed to examine the association between DS use and selected characteristics.
Seventy percent of older adults reported using ≥1 DS in the past 30 d; 54% of users took 1 or 2 products, and 29% reported taking ≥4 products. The most frequently reported products were multivitamin or mineral (MVM) (39%), vitamin D only (26%), and omega-3 fatty acids (22%). Women used DSs almost twice as often as men. Those not reporting prescription medications were less likely to take a DS than those reporting ≥3 prescription medications. The most frequently reported motivation for DS use was to improve overall health (41%).
The authors concluded that the use of DSs among older adults continues to be high in the United States, with 29% of users regularly taking ≥4 DSs, and there is a high concurrent usage of them with prescription medications.
I find these data impressive – but not in a positive sense, I hasten to add.
The level of DS use in the US is staggering. Considering that 90% (my estimate) of the supplements are completely useless, the amount of money that is being wasted is huge. Even more concerning is the frequency of drug interactions that are being provoked by DS-intake.
And what’s the solution?
Obviously, it is better information for consumers (which is easier said than done – but I am trying my best!).
Mastitis is a common disease in dairies. Numerous non-antimicrobial drugs and treatment strategies have been recommended for this condition. Homeopaths in particular have long claimed that their highly diluted remedies are an effective option, and I have reported repeatedly about the evidence – see here, here, and here, for instance. Even though it is far from positive, evangelic homeopaths like our friend Dana Ullman or naïve quackery-fans like Prince Charles claim that it is “as effective as antibiotics, the mastitis treatment of choice”.
So, who is right?
I am biased, homeopaths insist.
Ullman is a joke, any rational thinker must admit.
Prince Charles? … no comment.
What we need is an independent body to look at the data.
A new systematic review did exactly that. Its authors are highly respected and come from institutions that are not likely to promote bogus claims:
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Canada
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Canada
- Canadian Bovine Mastitis and Milk Quality Research Network, Canada
- Canadian Bovine Mastitis and Milk Quality Research Network, Canada
- Sherbrooke Research and Development Centre, Agriculture and Agri-Food Canada
- Canadian Bovine Mastitis and Milk Quality Research Network, Canada
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montreal, Canada.
It was performed with studies written in English or French selected from CAB Abstracts, PubMed, and Web of Science. All treatments other than conventional antimicrobials for clinical mastitis during lactation were retained. Only studies comparing the treatment under investigation to a negative or positive control, or both, were included. Outcomes evaluated were clinical and bacteriological cure rates and milk production. Selection of the study, data extraction, and assessment of risk of bias was performed by 3 reviewers. Assessment of risk of bias was evaluated using the Cochrane Collaboration tool for systematic review of interventions.
A total of 2,451 manuscripts were first identified and 39 manuscripts corresponding to 41 studies were included. Among these, 22 were clinical trials, 18 were experimental studies, and one was an observational study. The treatments evaluated were conventional anti-inflammatory drugs (n = 14), oxytocin with or without frequent milk out (n = 5), biologics (n = 9), homeopathy (n = 5), botanicals (n = 4), probiotics (n = 2), and other alternative products (n = 2). All trials had at least one unclear or high risk of bias. Most trials (n = 13) did not observe significant differences in clinical or bacteriological cure rates in comparison with negative or positive controls. Few studies evaluated the effect of treatment on milk yield. In general, the power of the different studies was very low, thus precluding conclusions on non-inferiority or non-superiority of the treatments investigated. No evidence-based recommendations could be given for the use of an alternative or non-antimicrobial conventional treatment for clinical mastitis.
The authors concluded that homeopathic treatments are not efficient for management of clinical mastitis.
Will this finally stop homeopaths from claiming that their placebos work for mastitis?
I would not count on it!
Insomnia is a ‘gold standard’ indication for alternative therapies of all types. In fact, it is difficult to find a single of these treatments that are not being touted for this indication. Consequently, it has become a nice little earner for alternative therapists (hence ‘gold standard’).
But how good is the evidence suggesting that any alternative therapy is effective for insomnia?
Whenever I have discussed this issue on my blog, the conclusion was that the evidence is less than convincing or even negative. Similarly, whenever I conducted proper systematic reviews in this area, the evidence turned out to be weak or negative. Here are four of the conclusions we drew at the time:
- The evidence for acupuncture as a treatment of insomnia is plagued by important limitations, e.g. the poor quality of most primary studies and some systematic reviews. Those that are sensitive to such limitations, fail to arrive at a positive verdict about the effectiveness of acupuncture.
- We conclude that, because of the paucity and of the poor quality of the data, the evidence for the effectiveness of auricular acupuncture for the symptomatic treatment of insomnia is limited. Further, rigorously designed trials are warranted to confirm these results.
- The evidence for valerian as a treatment for insomnia is inconclusive.
- Evidence from RCTs does not show homeopathy to be an effective treatment for insomnia and sleep-related disorders. (FACT, 2011, 16:195-99)
“But this ERNST fellow cannot be trusted, he is not objective!”, I hear some of my detractors shout.
But is he really?
Would an independent, high-level panel of experts arrive at more positive conclusions?
Let’s find out!
This European guideline for the diagnosis and treatment of insomnia recently provided recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations.
The findings and recommendations are as follows:
- Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence).
- A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence).
- Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence).
- Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).
I think, I can rest my case.
The goal of this study was to assess clinical outcomes observed among adult patients who received acupuncture treatments at a United States Air Force medical center.
This retrospective chart review was performed at the Nellis Family Medicine Residency in the Mike O’Callaghan Military Medical Center at Nellis Air Force Base in Las Vegas, NV. The charts were from 172 consecutive patients who had at least 4 acupuncture treatments within 1 year. These patients were suffering from a wide range of symptoms, including pain, anxiety and sleep problems. The main outcome measures were prescriptions for opioid medications, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDS) in the 60 days prior to the first acupuncture session and in the corresponding 60 days 1 year later; and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life.
The most common 10 acupuncture treatments in descending order were: (1) the Auricular Trauma Protocol; (2) Battlefield Auricular Acupuncture; (3) Chinese scalp acupuncture, using the upper one-fifth of the sensory area and the Foot Motor Sensory Area; (4) the Koffman Cocktail; (5) lumbar percutaneous electrical nerve stimulation (PENS); (6) various auricular functional points; (7) Chinese scalp acupuncture, using the frontal triangle pattern; (8) cervical PENS; (9) the Great American Malady treatment; and (10) tendinomuscular meridian treatment with surface release.
The results show that opioid prescriptions decreased by 45%, muscle relaxants by 34%, NSAIDs by 42%, and benzodiazepines by 14%. MYMOP2 values decreased 3.50–3.11 (P < 0.002) for question 1, 4.18–3.46 (P < 0.00001) for question 3, and 2.73–2.43 (P < 0.006) for question 4.
The authors concluded that in this military patient population, the number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being after receiving courses of acupuncture by their primary care physicians.
The phraseology used by the authors is intriguing; they imply that the clinical outcomes were the result of the acupuncture treatment without actually stating it. This is perhaps most obvious in the title of the paper: Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population. Association is not causation! But the implication of a cause effect relationship is clearly there. Once we realise who is behind this research we understand why: This study was funded by the ACUS Foundation as part of a Cooperative Research and Development Agreement with the 99th Medical Group, at Nellis Air Force Base.
The mission of Acus Foundation is to educate military physicians in the science and art of medical acupuncture, and to facilitate its integration into conventional military care… we are the most experienced team of physician teachers and practitioners of acupuncture in the United States. If they are so experienced, they surely also know that there are many explanations for the observed outcomes which are totally unrelated to acupuncture, e. g.:
- the natural history of the conditions that were being treated;
- the conventional therapies the soldiers received;
- the regression to the mean;
- social desirability;
- placebo effects.
In fact the results could even indicate that acupuncture caused a delay of clinical improvement; without a control group, we cannot know either way. All we can safely assume from this study is that it is yet another example of promotion masquerading as research.
Yesterday, I received this email from my favourite source of misleading information.
Here it is
We wanted to tell you about an unprecedented event that you won’t want to miss: the world’s largest Peace Intention Experiment that’s ever been conducted, webcast FREE on GAIA TV from September 30-October 5. It’s being hosted by Lynne McTaggart. You may know Lynne as the editor of WDDTY as well as books like THE FIELD, THE INTENTION EXPERIMENT, and her new book, THE POWER OF EIGHT. But she’s also architect of The Intention Experiments, a series of web-based experiments inviting thousands of her worldwide readers to test the power of thoughts to heal the world. Lynne has run numerous Peace Intention Experiments around the world – all with positive effects – but this time, she’s targeting America, in hopes of lowering violence and helping to end the country’s polarized society. These webcasts will be broadcast around the world, and best of all, they’re FREE for anyone to participate in. You’ll be joining tens of thousands of like-minded souls from around the world taking part in a LIVE Intention Experiment, and a team of prestigious scientists will monitor the effects…
END OF QUOTE
I must admit that I have been worried about world peace in recent months. One lunatic with nuclear power is enough to scare any rational thinker – but it seems, we currently have two!
After reading about Lynne’s experiment, I am not less but more worried.
Because, as far as I can see, she always gets things badly wrong.
I recently came across this article; essentially it claims that, in 1918, chiropractic proved itself to be the method of choice for treating the flu!
Here is a short quote from it:
Chiropractors got fantastic results from influenza patients while those under medical care died like flies all around. Statistics reflect a most amazing, almost miraculous state of affairs. The medical profession was practically helpless with the flu victims but chiropractors seemed able to do no wrong.”
“In Davenport, Iowa, 50 medical doctors treated 4,953 cases, with 274 deaths. In the same city, 150 chiropractors including students and faculty of the Palmer School of Chiropractic, treated 1,635 cases with only one death.”
“In the state of Iowa, medical doctors treated 93,590 patients, with 6,116 deaths – a loss of one patient out of every 15. In the same state, excluding Davenport, 4,735 patients were treated by chiropractors with a loss of only 6 cases – a loss of one patient out of every 789.
“National figures show that 1,142 chiropractors treated 46,394 patients for influenza during 1918, with a loss of 54 patients – one out of every 886.”
“Reports show that in New York City, during the influenza epidemic of 1918, out of every 10,000 cases medically treated, 950 died; and in every 10,000 pneumonia cases medically treated 6,400 died. These figures are exact, for in that city these are reportable diseases.”
“In the same epidemic, under drugless methods, only 25 patients died of influenza out of every 10,000 cases; and only 100 patients died of pneumonia out of every 10,000 cases…”
“In the same epidemic reports show that chiropractors in Oklahoma treated 3,490 cases of influenza with only 7 deaths. But the best part of this is, in Oklahoma there is a clear record showing that chiropractors were called in 233 cases where medical doctors had cared for the patients, and finally gave them up as lost. The chiropractors saved all these lost cases but 25.”
END OF QUOTE
So what does that sort of ‘evidence’ really show?
Does it prove that chiropractic is effective against influenza?
Does it even suggest that chiropractic is effective against influenza?
I think it shows that some chiropractors (like many homeopaths) are deluded to a point where they are unable to differentiate pseudoscience from science, anecdote from evidence, cause from effect, etc.
In the case you need more explanations, let me re-phrase this section from a previous post:
In the typical epidemiological case/control study, one large group of patients [A] is retrospectively compared to another group [B]. By large, I mean with a sample size of thousands of patients. In our case, group A has been treated by chiropractors, while group B received the treatments available at the time. It is true that several of such reports seemed to suggest that chiropractic works. But this does by no means prove anything; the result might have been due to a range of circumstances, for instance:
- group A might have been less ill than group B,
- group A might have been richer and therefore better nourished,
- group A might have benefitted from better hygiene,
- group A might have received better care, e. g. hydration,
- group B might have received treatments that made the situation not better but worse.
Because these are RETROSPECTIVE studies, there is no way to account for these and many other factors that might have influenced the outcome. This means that epidemiological studies of this nature can generate interesting results which, in turn, need testing in properly controlled studies where these confounding factors are adequately controlled for. Without such tests, they are next to worthless.
We have repeatedly discussed the fact that alternative medicine (AM) is by no means free of risks. I find it helpful to divide them into two broad categories:
- direct risks of the intervention (such as stroke due to neck manipulation, or cardiac tamponade caused by acupuncture, or liver damage due to a herbal remedy) and
- indirect risks usually due to the advice given by AM practitioners.
The latter category is often more important than the former. It includes delay of effective treatment due to treatment with an ineffective or less effective form of AM. It is clear that this will cause patients to suffer unnecessarily.
Several investigations have recently highlighted this important problem, including this study from Singapore which assessed the predictors of AM-use in patients with early inflammatory arthritis (EIA), and its impact on delay to initiation of disease-modifying anti-rheumatic drugs (DMARD). Data were collected prospectively from EIA patients aged ≥ 21 years. Current or prior AM-use was ascertained by face-to-face interviews. Predictors of AM-use and its effect on time to DMARD initiation were determined by multivariate logistic regression and Cox proportional hazards, respectively.
One hundred and eighty patients were included: 83.9% had rheumatoid arthritis, 57% were seropositive. Median (IQR). Chinese race, being non-English speaking, smoking and high DAS28 were independent predictors of AM-use. AM-users initiated DMARD later (median [IQR] 21.5 [13.1-30.4] vs. 15.6 [9.4-22.7] weeks in non-users, P = 0.005). AM-use and higher DAS28 were associated with a longer delay to DMARD initiation. Race, education level, being non-English speaking, smoking and sero-positivity were not associated.
The authors concluded that healthcare professionals should be aware of the unique challenges in treating patients with EIA in Asia. Healthcare beliefs regarding AM may need to be addressed to reduce treatment delay.
These findings are not dissimilar to results previously discussed, for instance:
- AM-use delays cancer diagnosis.
- The advice of non-medically qualified practitioners may delay cancer therapy.
- Chiropractic care may delay referral to effective treatment.
- Consultations with homeopaths can delay effective therapy.
The only solution to the problem I can think of would be to educate AM practitioners and the public such that they are aware of the issue and do everything possible to prevent such problems. But this is, of course, easier said than done, and it seems more than just optimistic to hope that such endeavours might be successful. The public is currently bombarded with misleading information and outright lies about AM (many of my previous post have addressed this problem). And practitioners would have to operate against their own financial interest to prevent these problems from occurring.
This means that treatment delays caused by AM-use and advice from AM practitioners are inevitable…
unless you have a better idea.
If so, please let me know.