One of the core messages of Science-Based Medicine has been the same for 14 years. We've lamented how easy it is for doctors who are antivaxxers, grifters, and quacks to get away with practicing medicine without repercussions. We have advocated for change to empower state medical boards and specialty boards to hold doctors accountable for professional misdeeds, up to and including revocation of their medical licenses and board certifications. Without a medical license, a physician can't practice, as well as Medicare and Medicaid, and most insurance companies require it to reimburse a physician, and most hospitals require it to grant privileges. Stanislaw Burzynski, a Texas cancer quack, has been charging large consultation fees to treat cancer patients since the late 1970s. The Texas Medical Board and the FDA imposed sanctions on Dr. Burzynski for his clinical trials that were designed, but he was able to avoid them. The President and CEO of the American Board of Internal Medicine, Richard J. Baron, wrote an op-ed in the New England Journal of Medicine. I think you know how I will answer, but first I want to give you a little context.
Burzynski pioneered the technique that we see so much in evidence today; he recruited his patients to use for PR and politics to spread misinformation about cancer and health freedom.
The threat to public health from physicians promoting quackery and misinformation quickly became a global threat after the COVID-19 Pandemic hit. The usual physician suspects from the past, whom we had long been writing about. There is now a veritable army of quacks, some of whom are into serious grift, but all of whom are spreading dangerous misinformation.
The problem of toothless state medical boards, how easily bad and even dangerous doctors can keep practicing, and how oblivious our fellow physicians had been to the threat of medical misinformation before the Pandemic had been written about before. I noted at the end of 2020 how physicians behaved badly in the previous year. It's worth quoting myself from nearly a year and a half ago, before I discuss the NEJM op-ed.
If anything, the COVID-19 pandemic has reinforced my opinion, first stated 12 years ago, that medical practice itself is a sadly weak check on BS, particularly when the medical system is stressed. Just look at the list of examples that I’ve discussed in this post and realize that there are many more that I could have discussed if I didn’t mind having this post balloon up to 10,000 words or more. The point, of course, is that all too often we physicians view ourselves as relatively immune to being led astray by “BS”, certainly far more so than others. It is that arrogance that leads to doctors like Dr. Scott Atlas pontificating on areas of medicine that he doesn’t understand and then portraying himself as Galileo when criticized for it. Don’t believe me?
After listing a number of examples of physicians spreading dangerous COVID-19 misinformation, as well as historical examples, such as Stanislaw Burzynski, Christopher Duntsch, and others, I concluded:
The bottom line is that practicing medicine is a privilege, one of the highest privileges society can grant to any human being. It is not a right. Unfortunately, all too often the law treats it more like a right, with state medical boards being loathe to strip quacks and other doctors practicing inarguably substandard medicine of their privilege to practice. That needs to change, and that change needs to include stopping physicians from abusing the privilege of their profession to spread disinformation that kills, as too many physicians did in 2020 and, sadly, are likely to continue to do in 2021.
We are not far from the halfway point in 2022. What happened? The good news is that the Federation of State Medical Boards made a statement a year ago asserting that spreading dangerous medical misinformation could be grounds for a lawsuit. The targeting of state medical boards is nothing new. It has been a tactic of antivaxxers and quacks to target state medical boards legislatively. Legislators used to be prodded by powerful pseudomedicine interests. In 2010, Buttar led a successful effort by the North Carolina Integrative Medical Society to persuade legislators to change state law to make it friendlier to alternative medicine practitioners. The medical board in North Carolina can't discipline a doctor for using non-traditional treatments unless it can prove they are more harmful than the prevailing treatments. It is happening on a scale I have never seen before.
A new medical advocacy group, No License for Disinformation (NLFD), has been formed and advocates to state medical boards and specialty medical boards to take misinformation seriously and even sanction doctors who promote it. Since it was formed, NFLD has gained access to state medical board officials and specialty boards. I saw statements like this about a proposed California law that would empower its citizens, and they were very resistant to such efforts.
If your dr is treating you for Covid or goes beyond the guidelines to save you, Appreciate him or her because these are the most trying times for drs. Not only do we have to stress about every lives we take on but now we have to fight boards . This is coming I’m sure
pic.twitter.com/JC2m85dXmH
— sabine hazan md (@SabinehazanMD) May 19, 2022
Physicians for Informed Consent is a group of antivax physicians.
Let's look at the NEJM editorial.
The opening of the NEJM op-ed on medical misinformation is hard to argue against.
Medicine has a truth problem. In the era of social media and heavily politicized science, “truth” is increasingly crowdsourced: if enough people like, share, or choose to believe something, others will accept it as true. This way of determining “truth” doesn’t involve scientific methods; it relies instead on “the wisdom of crowds,” which has particular power in a democratic society in which leaders and policies are chosen by the will of the group. Such choices anchor concepts like freedom and liberty. But they may not be helpful in determining whether a building will collapse, whether your brakes will stop your car — or whether a medication or vaccine works.
Growing allegiance to crowd-endorsed “facts” poses a serious challenge for the institutions and structures that the medical enterprise has developed to protect the public and ensure that people can tell who can or cannot be trusted as medical professionals or relied on for scientific knowledge. These structures include comprehensive medical education, licensure, and board certification, and leaders in all these areas are struggling to figure out how to respond to assertions by doctors on social media that are not supported by evidence and may harm patients. The Surgeon General has identified medical misinformation as a major public health threat, and many professional societies, including the American Medical Association, have called for action to combat it.
We have been telling the medical profession, state medical boards, etc., for over 14 years. Some of its members have been warning about it before, but this is nothing new. Val Jones, one of our writers, created a term for the attitude of physicians about alternative medicine, medical misinformation, antivaccine pseudoscience, and the like.
Shruggie (noun): a person who doesn’t care about the science versus pseudoscience debate. When presented with descriptions of exaggerated or fraudulent health claims or practices, their response is to shrug. Shruggies are fairly inert, they will not argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general. They simply aren’t all that interested in the discussion, and are somewhat puzzled by those who are.
Sound familiar? More than two years into the Pandemic, there are still a lot of shruggies in the medical profession.
It has been more than just social media, at least not at the massive scale it does now. The problem had been going on for a long time on websites, internet discussion forums, Usenet, and old-fashioned email lists. The rise ofcomplementary and alternative medicine was one of the reasons for the profession of medicine. Let's put it this way. When there are academic departments in medical schools that promote quackery, it makes sense that medical academia would be reluctant to confront those in its ranks who promote COVID-19 contrarianism.
Baron and Ejnes wrote a note.
The issue of what physicians can and cannot say on social media has been hotly debated by legal scholars and in medical journals. Coleman has observed that “professional speech” is a legally contested domain between speech that can be regulated or prohibited by licensing boards and speech protected by the First Amendment. It is also unclear when physicians’ speech on social media constitutes “medical practice.”1 Mello has questioned why First Amendment protections should extend to harmful speech that leads to death from preventable disease, when some other forms of speech — such as fraudulent commercial speech, which may be less harmful — are prohibited.2
It is also true. There is a bright line between misinformation/disinformation and legitimate, and no one has claimed that there is a bright line between physicians who use their status as trusted professionals to give a patina of science and the authority of medicine to fraud and conspiracy theories. The ABIM asks the right question, "Do Right and Wrong Answers Still Exist in Medicine?"
Exactly!
I agree with Baron and Ejnes that there are answers that are clearly wrong in medicine. They do exist. As new evidence comes in, cranks and quacks like to argue that they are doing nothing more than engaging in a debate. Baron and Ejnes used an example of how ABIM certifying exams are constructed to trap those who don't know much about the topic.
Creating these exams involves bringing together academic and practicing expert clinicians from a particular field to write and critique multiple-choice questions that have a single best answer — a process that may provide a useful perspective on somewhat analogous efforts to assess the information that doctors and others disseminate through informal public channels such as social media. The challenge in writing multiple-choice exam questions is not constructing a question with a right answer; rather it’s creating the “distractors,” the wrong but plausible answers. As anyone who has taken a multiple-choice exam knows, even someone with no knowledge of the relevant field can pass a test when the wrong answers are obviously implausible. An exam question measures something important only if someone acquainted with the field might believe the wrong answers are correct. The expert clinicians spend most of their time debating the distractors: Is that answer really wrong? If anyone around the table can find a valid article that might support the choice of option C as correct, then option C can’t be used as a distractor. In these discussions, the experts are guided by peer-reviewed medical literature, not by “prevailing opinion” or what a committee member believes; they don’t take polls. They accept the methods underlying scientific studies as a safer guide to practice than the received wisdom, intuition, or even “democratic process.” Informed by that literature, they conclude that some answers are definitively wrong.
Quality control is also done in such exams. The question may be thrown out or modified for future versions of the examination if certain wrong answers are chosen at too high a Frequency. There are answers that are plausible but still wrong.
There is a huge difference between the example of exam questions and distractors and the real world misinformation being promoted by physicians. Doctors tend to be good at cherry picking seemingly scientific papers that are published in the peer-reviewed medical literature to support their misinformation. There are no papers to support a particular answer in the problem of misinformation. In addition, physicians can be really good at misrepresenting or distortioning the findings of legitimate scientific publications in the service of their disinformation, be it demonizing COVID-19 vaccines, claiming that masks don't work to slow the spread of COVID-19, or arguing that COVID-19 is Brandolini's law states that the amount of energy needed to refute bullshit is an order of magnitude bigger than it is to produce it. It takes at least two orders of magnitude more time and effort to refute bullshit as it does to produce it, and the doctors who spread it are very good at doing that. The example used by Baron and Unje is simplistic and doesn't take into account the full magnitude of the misinformation problem. I think they are starting to get it.
As the ABIM confronts the danger of medical misinformation, we recognize that there are many clinical issues on which physicians legitimately hold a spectrum of opinions, all supported by evidence; such justifiable positions would not make it as “distractors” on our exam, nor would they meet our definition of “false information,” as determined by experts consulting the literature. A whole range of statements with which many — or even most — physicians might disagree would therefore not trigger our disciplinary process. On the other hand, when someone certified by the ABIM says something like “the origin of all coronary heart disease is a clearly reversible arterial scurvy” or “children can’t spread Covid” or “vaccines don’t prevent Covid deaths or hospitalizations,” we are not dealing with valid professional disagreement; we are dealing with wrong answers.
Baron and Unje didn't just mention false claims about COVID-19, but also about heart disease. The problem of medical misinformation being spread as health freedom anddemocratization of medical knowledge suggests that they now recognize that.
Conspiracy theories include that COVID-19 is a plandemic, casedemic, or vaccine that contains chips. I am a bit worried. I have to wonder if there is a bright line between a wrong answer that is plausible enough to be a distractor and a bullshit answer. I didn't see any mention of the ABIM consulting experts in conspiracy theories. Many times throughout our 14 years of existence, we have documented how physicians are confused when they encounter medical misinformation. They don't have the background to adjudicate anything in the gray areas, and sometimes struggle with cases that are obvious to those of us who study quackery and misinformation.
I applaud ABIM for starting to grapple with the issue of its diplomates spreading medical misinformation and disinformation, even if they are late and appear to have a bit of a naive view of what medical misinformation and disinformation are. I hope that they will learn that it is easier to do something meaningful than it is to be on a state medical board.
The ABIM is one of many boards that certify various medical specialties. I am certified by the American Board of Surgery, but no other board besides ABIM has yet gone as far. I hope that I won't be able to say that in a year.
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