Eliminating Conflicts of Interest in Medical Research

Eliminating Conflicts of Interest in Medical Research
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The medical profession appears more interested in disclosing and “managing” conflicts of interest than prohibiting them.

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Who funds most of the studies that show that drugs are safe and effective? The drug companies themselves. It is self-evidently absurd to look to investor-owned companies for unbiased evaluations of their own products. One result of the bias in the medical literature is, then, that physicians learn to practice a very drug-intensive style of medicine—even when lifestyle changes would be more effective. Physicians and their patients often believe that for every ailment, there’s a drug.

It’s gotten so bad that physicians can no longer rely on the medical literature for valid and reliable information. Wow, that’s quite an accusation. Says who? Says a long-time editor of one of the most prestigious medical journals in the world.

To help expose some of these conflicts of interest that are corrupting the medical profession, the Drug Company Gift Disclosure Act was introduced into Congress, and died there year after year, until it was successfully integrated into the Affordable Care Act. And now, there’s a database detailing which doctors get the billions of dollars dished out, permitting patients to make better informed decisions when choosing health care professionals and making treatment decisions. In a previous video, Find Out If Your Doctor Takes Drug Company Money, I described how you could look up your own doctor.

The 2008 version that medical groups endorsed didn’t require public disclosure, unless doctors got $500 in gifts. But the 2009 version got even stricter, requiring disclosure if you even pocketed $100, leading groups like the American Academy of Family Physicians to start to get a little nervous. But the final wording in Obamacare requires disclosure of even a $10 meal, leading countries around the world to look to the United States of America for leadership in health care ethics—you don’t see that every day.

Now that we have this massive public record, we can now really see how honest doctors have been. The financial disclosures by the authors of the American College of Cardiology and American Heart Association guidelines were matched to the public disclosures of the hundreds of thousands of dollars they received from Big Pharma, thanks to the new law. And let’s just say the overall agreement between author and company disclosure was poor.

Nationally, female physicians each received thousands fewer dollars, on average, each year from drug companies—though it’s not clear if this is because the women were ethical, or the industry was sexist.

What about conflicts of interest online? There are purportedly evidence-based medicine websites allowing physicians to answer clinical questions at the bedside. For example, clinicians caring for patients are increasingly reviewing treatment recommendations on these websites to make clinical decisions in real time. You’re with a patient; you can just whip out your phone and check. So, it’s important that there are no financial conflicts of interest in those that write these online guidelines. So, they examined one such website called UpToDate, which seemed to provide the most comprehensive diagnoses. So, did they find any conflicts of interest? Yes, in every single UpToDate article they looked at.

Okay, but so what do you do with that information? Let’s say you see an article claiming that candy consumption is not associated with health risks, and they disclose that the research was supported by the National Confectioner’s Association—who used to run ads that said things like: “Put candy in their school lunch because it’s good for them.” The problem with financial conflicts of interest is that you simply don’t know what to believe.

So, maybe this preoccupation with disclosure hijacked the whole debate. Maybe, as the former editor-in-chief of the New England Journal of Medicine critiqued, the focus should be instead on not just disclosing, but eliminating commercial conflicts. It’s like campaign finance reform, where the issue is managed more by public disclosure, rather than getting money out of politics.

Dr. Kassirer writes that the vast attention paid to failure to disclose conflicts of interest is misplaced, and that more attention should be focused on the financial conflicts themselves. After Dr. Kassirer effectively resigned from the New England Journal of Medicine, disillusioned with the direction they were taking, Dr. Angell took over. The first female editor-in-chief in the journal’s hundred year history. She lasted about a year. Medical journals “consistently refer to ‘potential’ conflicts of interest,” she wrote, “as though that were different from the real thing, and about disclosing and ‘managing’ them, not about prohibiting them. In short, there seems to be a desire to eliminate the smell of corruption, while keeping the money. Breaking the dependence of the medical profession on the pharmaceutical industry will take more than appointing committees. It will take a sharp break from an extremely lucrative pattern of behavior.”

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

Please consider volunteering to help out on the site.

Image thanks to Bill Brooks via flickr

Who funds most of the studies that show that drugs are safe and effective? The drug companies themselves. It is self-evidently absurd to look to investor-owned companies for unbiased evaluations of their own products. One result of the bias in the medical literature is, then, that physicians learn to practice a very drug-intensive style of medicine—even when lifestyle changes would be more effective. Physicians and their patients often believe that for every ailment, there’s a drug.

It’s gotten so bad that physicians can no longer rely on the medical literature for valid and reliable information. Wow, that’s quite an accusation. Says who? Says a long-time editor of one of the most prestigious medical journals in the world.

To help expose some of these conflicts of interest that are corrupting the medical profession, the Drug Company Gift Disclosure Act was introduced into Congress, and died there year after year, until it was successfully integrated into the Affordable Care Act. And now, there’s a database detailing which doctors get the billions of dollars dished out, permitting patients to make better informed decisions when choosing health care professionals and making treatment decisions. In a previous video, Find Out If Your Doctor Takes Drug Company Money, I described how you could look up your own doctor.

The 2008 version that medical groups endorsed didn’t require public disclosure, unless doctors got $500 in gifts. But the 2009 version got even stricter, requiring disclosure if you even pocketed $100, leading groups like the American Academy of Family Physicians to start to get a little nervous. But the final wording in Obamacare requires disclosure of even a $10 meal, leading countries around the world to look to the United States of America for leadership in health care ethics—you don’t see that every day.

Now that we have this massive public record, we can now really see how honest doctors have been. The financial disclosures by the authors of the American College of Cardiology and American Heart Association guidelines were matched to the public disclosures of the hundreds of thousands of dollars they received from Big Pharma, thanks to the new law. And let’s just say the overall agreement between author and company disclosure was poor.

Nationally, female physicians each received thousands fewer dollars, on average, each year from drug companies—though it’s not clear if this is because the women were ethical, or the industry was sexist.

What about conflicts of interest online? There are purportedly evidence-based medicine websites allowing physicians to answer clinical questions at the bedside. For example, clinicians caring for patients are increasingly reviewing treatment recommendations on these websites to make clinical decisions in real time. You’re with a patient; you can just whip out your phone and check. So, it’s important that there are no financial conflicts of interest in those that write these online guidelines. So, they examined one such website called UpToDate, which seemed to provide the most comprehensive diagnoses. So, did they find any conflicts of interest? Yes, in every single UpToDate article they looked at.

Okay, but so what do you do with that information? Let’s say you see an article claiming that candy consumption is not associated with health risks, and they disclose that the research was supported by the National Confectioner’s Association—who used to run ads that said things like: “Put candy in their school lunch because it’s good for them.” The problem with financial conflicts of interest is that you simply don’t know what to believe.

So, maybe this preoccupation with disclosure hijacked the whole debate. Maybe, as the former editor-in-chief of the New England Journal of Medicine critiqued, the focus should be instead on not just disclosing, but eliminating commercial conflicts. It’s like campaign finance reform, where the issue is managed more by public disclosure, rather than getting money out of politics.

Dr. Kassirer writes that the vast attention paid to failure to disclose conflicts of interest is misplaced, and that more attention should be focused on the financial conflicts themselves. After Dr. Kassirer effectively resigned from the New England Journal of Medicine, disillusioned with the direction they were taking, Dr. Angell took over. The first female editor-in-chief in the journal’s hundred year history. She lasted about a year. Medical journals “consistently refer to ‘potential’ conflicts of interest,” she wrote, “as though that were different from the real thing, and about disclosing and ‘managing’ them, not about prohibiting them. In short, there seems to be a desire to eliminate the smell of corruption, while keeping the money. Breaking the dependence of the medical profession on the pharmaceutical industry will take more than appointing committees. It will take a sharp break from an extremely lucrative pattern of behavior.”

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

Please consider volunteering to help out on the site.

Image thanks to Bill Brooks via flickr

Doctor's Note

Why does the funding source matter? See my previous video, Disclosing Conflicts of Interest in Medical Research.

Want to look up your own doctor? Check out Find Out If Your Doctor Takes Drug Company Money.

The shameful practices of supposed science-based medicine websites, like UpToDate, are the very reason I started NutritionFacts.org—to share the best available evidence without corrupting commercial influence. If you value my work, please consider becoming a supporter by making a recurring monthly donation to the 501c3 nonprofit that keeps NutritionFacts.org growing and thriving.

If you haven’t yet, you can subscribe to my videos for free by clicking here.

36 responses to “Eliminating Conflicts of Interest in Medical Research

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  1. “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!” – Upton Sinclair

    Unfortunately, doctor’s are not compensated for successfully promoting health.




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    1. Considering that most treatment approaches other than lifestyle modification fail to actually stop the progression of any chronic disease let alone cure them, perhaps doctors, with the exception of those all too few who are fully woke to the power of lifestyle change, should stop referring to themselves as “healers” and instead call themselves what they actually are, “symptom managers”.




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      1. OK, I want to walk some of this back as it comes across as really bad doctor bashing. I think doctors are awesome. The vast majority truly want to help their patients. The trouble is that they don’t get any substantial education in nutrition and so are left to pick it up on their own. And that is where I think the trouble starts. With regard to food culture doctors were raised just like everybody else in a culture where consumption of meat, dairy and eggs is not just the norm but expected. As such not eating animal products is just not in their cognitive sphere. So while doctors know their patients need to eat a healthier diet, unconsciously perhaps, they frame those diets in the context of cultural norms. As a result those healthier diets always contain animal products. And being of a scientific mind-set doctors do read research articles. The trouble is that doctors are no less prone to confirmation bias than anybody else, and so are very susceptible to finding the skewed results of biased industry funded studies compelling when they confirm what they already “know” to be true.

        Compounding this is the additive nature of western medicine where the expectation is that doctors will add new factors, pharmaceutical or procedural, directed at moving the patient forward from their current state of ill-health to a state of health. In essence patients expect the doctor to “do something” to make them feel better, and doctors are trained to do just that. As such “subtractive” medicine such as lifestyle with removal of harmful foods from the diet is not seen as doing anything to specifically address the issue that brought the patient to see the doctor. So instead of removing the cause of a condition, the western approach it to add something. For infectious disease in the age of anti-biotics/fungals/parsitics that is absolutely the right approach, and adding something cures the patient. But where lifestyle is the root cause, adding pill after pill has little to no effect on the disease itself. At best it controls the most dangerous symptoms of the disease like high blood sugar in diabetics.

        Thus both factors work against doctors even seeing truly fundamental lifestyle changes which removes animal products as “medicine”. Instead they know that more fruits and vegetables is healthier, but the best they can do is try to add them to a normal diet that contains animal products and justify keeping animal products as “all things in moderation”. And of course when such unhealthy “healthy diets” fail to halt let alone reverse the diseases of their patients, they see this as confirmation that “subtraction” medicine doesn’t work and the only hope these people have is their additive approach of pills and procedures.

        I am hopeful however given the numbers of doctors one hears about, such as those that participate in this forum, that are waking up to the power of eating to not only avoid chronic diseases, but also halt and reverse them as well. My feeling is that we are fast approaching a tipping point where not eating animal foods is becoming fully normal enough that doctors will cognitively be able to accept the research showing the powers of plant based diet to do what pills can’t do. Hopefullly they will thenadd a therapeutic WFPB diet as a primary treatment modality as a first course of action and proscribed it in the same way and with as much firmness and conviction as any course of medication. Even more importantly I think that a significant percentage of the population knows someone close to them that is vegan or plant-based that have actually reversed disease or just lost weight and become really healthy. As such they are primed to be able to fully internalize their doctor’s message to that they can heal their diabetes or heart disease or high blood pressure with diet instead of pills and surgery.




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        1. Well said I think. I am a doctor who didn’t “discover” nutrition science until after retirement. Part of the problem is that receive our medical journals in electronic form now. At least in the past we could see a nutrition article as we flicked though our paper journal. Now we set our interests list and now we can practice our whole lives and not see a nutrition article. I would pracrice very differently now if I went back into patient care.




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  2. Angell’s book called The Truth About the Drug Companies was a real eye opener for me. Glad to see her efforts being recognized by Nutrition Facts! Also, thanks for bringing up campaign finance reform – that’s hella important for healthcare, but also for democracy in general.




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  3. One of the best videos. Should patients be called victims? If there were not money involved, it could be thought of a natural mistake. But money is a source of motivation that bias reasoning. Thus, the people that benefit from the process are inclined to see themselves as the good guys.

    https://en.wikipedia.org/wiki/Motivated_reasoning

    “When people form and cling to false beliefs despite overwhelming
    evidence, the phenomenon is labeled “motivated reasoning”. In other
    words, “rather than search rationally for information that either
    confirms or disconfirms a particular belief, people actually seek out
    information that confirms what they already believe.”

    In this sense, emotions are shown to color how “facts” are perceived.
    Feelings come first, and evidence is used mostly in service of those
    feelings. Evidence that supports what is already believed is accepted,
    that which contradicts it is not.




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  4. growing up I was taught that you could trust doctors that they took an oath .I was at the hospitable with a friend the other day who had some blood drawn and checked for levels of iron and what ever else they check for I asked the doctor if the iodine levels were checked he said no they don’t check that iodine it is poison .I said what ?So I should I toss out my poisons table salt ? he did no answer me and kind of gave me a dirty look .I did not mean to be a smart butt ,but if I been reading studies right the country in many areas is suffering from low levels of iodine .I been witching videos on this site and find them very informative .I have a mind fog over the many different opinions there is .So its up to us the reader or watcher to make the best choice that we can make from whom we believe to be correct .I compare notes and if there seems to be a seemlier opinion I tend to go with that. I have one question there is a group (s) of people running around saying that alkaline water is good for you ? AND there is another selling a filter system that makes free hydrogen in your drinking water claiming this is better for you can any one point me in any studies on this so I can make an informed decision on this topic thank you cheers and may you have good health .




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    1. The alkaline water ad I see really makes me laugh. They say something about now you can get what everyone is talking about to get your own health benefits. Really! The only everyone talking about it is that ad.




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    2. I’ve read that you can make your body chemistry far to alkaline by drinking alkaline water. When this happens your body needs to compensate somehow to bring the excess alkalinity back to a normal Ph level. The process of constantly trying to keep your blood Ph level neutral is stressful and not good for you.




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  5. I understand the frustration people have with the medical community. As is true for every human endeavor there are people who constantly strive to be the best and those who are complete screw ups, those who are morally sound and those who would sell their child’s kidney (I hope I’m exaggerating on the last one). Some of the doctor bashing comments are a bit reductionist though to use a Dr. Greger phrase. The fact that a patient got sick, went to the doctor and remains sick doesn’t mean that going to the doctor is unhelpful. Patients must play an active role in their own health. I’m an endocrinologist and see this problem daily. I want people to get better, get off their drugs, feel great and be healthy. That’s why I became a doctor and I think that is true for the majority of us. Part of the problem is getting over the inertia of being unwell, following bad habits, looking for a quick fix with little or no effort. Both doctors and patients are at risk to this. Remember, the fact that you are reading this is a selection bias. You are obviously interested in your own health, probably follow a WFPBD, and I hope very much that you are healthy. I can tell a person they have a life threatening metabolic disease called type 2 diabetes that increases their risk of heart disease, stroke, kidney failure, blindness, amputation, etc. I can discuss treatment options including medications then explain how they can reverse their disease with WFPBD. I give them a four page summary of the diet I follow, why I do it, the research behind it and multiple online and published resources to succeed with (including this site and HNTD of course!). Some follow through but actually most continue to eat fast food, sugar, and no fiber outside of a little breakfast cereal. It’s very frustrating but it is their choice and I can’t make them change. I continue to recommend it, I live it and discuss my own health improvements from doing it (30 pound weight loss, less medication, lower blood pressure, lower cholesterol, etc.) So, we doctors need help with the message. We need more friends and neighbors, church members and classmates to help spread the word. Make the change to healthy eating not “weird” and maybe those of us who are sending the message can be more effective.
    God Bless and Good Health




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    1. Excellent post Sugar_Doc. One other thing to add is that, much like tobacco companies, pharmaceutical companies “hook ’em while they’re young.” What I mean is that medical schools spend months teaching pharmacology and hours to days teaching lifestyle (nutrition, exercise, etc). Also, medical students, interns and residents get lured by pharma lunches, dinners, etc. It’s not a mistake. Things are better than say 15 years ago, but not much better.
      Progress is happening, but way too slowly. Physicians like you and I need to keep plugging away with our patients as well as any students, residents, colleagues as we can.




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      1. Excellent points. I will keep repeating the message. Two of our Family Doctors in town understand the benefits and live it. DTC advertising needs to go away too. It’s confusing and reinforces the message that you need drugs to get well. We need good medicines of course but we need to retrain ourselves and patients that they don’t have to be forever and there are better long term therapies with healthy living and eating.




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    2. My sister had diabetes, HBP, but kept indulging her appetite and just took more meds. That was just her attitude to eat whatever she felt like so what if she died early. But finally with failing kidneys and plugging arteries she changed her way of life and is now and Esselstyn follower. But most of her life if any doctor suggested lifestyle change she just changed doctors.




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      1. Thanks for your comment. I see patients like your sister all too often. I pray that she continues to recover and heal. It’s heartbreaking when a patient goes from a state of being curable to one of damage control. I hope she can be a role model for others to avoid the suffering she endured.




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    3. Sugar_Doc, Thank you very much for this. I can sometimes get overly cynical when my impressions are that so many who could be such a force for change are instead a major part of the problem. This includes doctors, but mostly those who corrupt the medical system from one focused on healing to one that maximizes profits. But at the top of my list are those who set dietary policy. So reading about your frustrations trying to get the blind to see helps me to maintain perspective.

      So I have a question. My layman’s understanding is that the root cause of diabetes is insulin resistance, and without insulin resistance, and of course a pancreas that can still produce insulin, diabetes will simply go away. And from the information presented here it sounds like insulin resistance is fully reversible through diet, if not for everyone, at least for the vast majority. So my question is, is insulin resistance a choice, at least for the majority who can reverse their insulin resistance? And since the patient is the locus of control, as Dr. Esselstyn loves to say, with respect to diet, is it really as simple as the patient making a deliberate choice to cure their diabetes or choosing to remain diabetic?

      I’m really not trying to blame the patient here. I understand just how powerfully addictive food can be not to mention how confining culture and tradition can be to what one can even conceive of let alone consider. But if diet can reverse the root cause of the disease, then it would seem that it is indeed a choice. Perhaps presented that starkly they might view diet differently. More as medicine and treatment and less than nagging to “eat better”. Not that I think that is what you do, just that they have probably been badgered to eat better for years before their poor diet lands them in your waiting room.

      But like anybody in recovery, they are likely going to need help getting the meat monkey, not to mention the cheese monkey off of their backs, especially since their personal support system is likely to be anything but supportive in this case. So are there support groups that you can refer them to? If you aren’t already doing this perhaps in partnership with a like-minded dietitian and possibly a chef (a cooking dietitian!) you could start one to provide guidance and education but most especially acceptance and reassurance as your patients leave the comfort of the known for the vicissitudes of the unknown.




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      1. Jim, Thanks for your comments. I read your earlier comment follow up and appreciated that too. I agree with everything you said and tried to post a brief comment earlier this week but had difficulty logging in for some reason.
        Don’t feel bad. I share you enthusiasm and have deleted many lengthy posts after re-reading them. It’s a natural danger of online written word. Things can innocently be taken out of context from what the author meant.
        The insulin resistance model is certainly one of the more popular models of developing type 2 diabetes (type 1 is autoimmune but can have insulin resistance as part of it’s problem). Like all complex systems the development of type 2 diabetes is multifactorial including family history, body weight, diet, activity (or lack there of) and other illness like cardiac disease. The presentation can take different forms for different people. The core common link though is diet. ALL patients can get better by switching to a better diet. Most could st op insulin, many can reduce and come off medications completely. This is well documented and I’ve witnessed it many times in my own practice.
        So is type 2 diabetes a choice? Well I suppose that depends on your point of view. Many people are truly confused about what a healthy diet is. The most common things they tell me when I ask a new patient about their diet is they eat a lot of chicken because that’s “good” and “try” to stay away from carbs because they “know they are bad but sometimes [they] cheat.” People who are truly motivated to get off meds tend to figure much of it out on their own. Once I’ve given them the scoop on what a healthy diet should look like though, yes. I suppose it’s their choice to do that or continue to eat the same things that caused their type 2 diabetes to begin with.
        Food is no different than other bad habits or addictions. People recognize it’s bad for them but continue to do it anyway. I think it’s human nature to destroy ourselves a little at a time. No one would argue that putting a gun in your mouth is suicidal but putting doughnuts and bacon in the mouth of a cardiac patient or diabetic is suicide by the fork… it just takes longer. Society lacks subtlety though. Everything has to be bold type, fast result, dramatic, or take little effort. That’s our unfortunate culture. I hope it can change but it is a tremendous battle with what appear to be insurmountable obstacles.
        For my part I do what I can. I practice in rural Kentucky. My wife and I still run our own office but that gets harder all the time. Health policy initiatives for “quality of care” are a thinly veiled tactic of the Feds and big business to gain access and control over health care data and financial streams. At some point in the near future I’ll probably be forced out of doing things my way. Your ideas about the dietician are great and I’ll give that some thought. The funding would be the issue. That person’s time needs to be compensated, insurance paid, office space rented, etc. It quickly becomes an idea that will cost several hundred thousand dollars to make happen before the first patient can be seen.
        Support groups can be wonderful and they do come and go over time. Our health department has a good doctor at it’s helm now and she is trying to make good things happen in our community too. We have some family doctors who also see the truth behind good nutrition and do their best to educate. I’m hopeful someday we can pool our minds and efforts to make a larger impact for our community.
        Best wishes!




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  6. There is definitely a strong need for whistle blowers in the healthcare industry. I wonder if we will hear a lot more about the political issues related to how drugs are tested, the political process involved in approving the drugs, how the efficacy of drugs are determined and how to remove the flow of the money from advertising, “contributions” to those in various decision nodes, and lobbyists into the health CARE system. Who in the power seats are strong enough to hang the bell on the cat’s neck? Then there is the question of insurance industry and their wasteful role in the care process….




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  7. I don’t see any change in cronyism, under the table payoffs, and “deals” ever happening in the future for most human activities. There are degrees of corruption in every government, in every country, and in every human activity weather it is religion, law, military, education, business, entertainment, construction, and on and on and on. I agree with some of the earlier posts that encourage all of us to be on guard, educated, and to always recognize the reality and truth of every situation we find ourselves in.




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  8. Seems no one except Joe Caner got the final message here in the video/transcript. The lie is that disclosure of conflict is the answer (that fits the abusers practices) instead of accountability and that $$$$$$$$$ power is the “candy” that attracts physicians to play the game. In a capitalist democracy/economy, that will never change. And speaking of this, it is not a democracy when 10% of the U.S. population owns 60% +- of the countries wealth and thus the political power as well. Reformists (most Americans) will promise that change is possible and apologists like Jim Felder will do their best to placate (with unnecessary long diatribes) the impressionistic minds in our midst….which are many. It will only get worse, if past is prologue.




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  9. What a goofy, hard-to-listen-to speaking voice. Couldn’t they find somebody who speaks normally? Appreciate the info… just wish it was presented in a less annoying manner.




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  10. What ever happens to the China study debunker Denise Minger. I tried to follow both sides of the argument but honestly it’s just a complete mess.




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  11. OK, I made a comment……where is it? Was it political and censored? Jim Felder and Sugar Doc sure seem to be taking up their share of comment space. And Fedler isn’t saying anything Public Citizen hasn’t said about the conflicts of interest in Health care for years? Whos the gatekeeper here? Can I get an explanation why my comment was removed?




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    1. Jim: I looked through the deleted posts and found one from you. There are multiple moderators on this site. We don’t delete many posts and I’m not 100% sure why that one post was deleted. Looking at it, I could say that your post contained what could be seen as a personal attack on another member of this community. Please review the posting rules for this site. You can find the rules under the FAQ link at the bottom of the page. Can you state your opinions without attacking others on this site? That would be safest.




      0
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  13. hi everybody!
    Im currently confused on whether magnesium stearate in supplements can be harmful, harmless or helpful.
    I’ve seen arguments for both sides of the argument.
    can anyone clarify if it is safe?
    Thanks!




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  14. Hi Everybody!
    I’m struggling to find reliable info on the safety of magnesium stearate found in various supplements etc.
    can anyone point me in the direction of a reliable source or advise if it is harmful, harmless or helpful?
    Thanks!




    0

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