The ABIM vs. medical misinformation: Better late than never?

Over its 14 years of existence, one of the core messages of Science-Based Medicine has been very consistent. We have bemoaned how easily doctors who are quacks, antivaxxers, and grifters not only manage to avoid professional penalties and keep their medical licenses and board certifications, but often to keep practicing more or less unimpeded by either state medical boards or the private boards that certify them in their chosen medical specialties. Flowing from this dismay, we have also advocated for change to empower state medical boards and specialty boards to hold doctors accountable for professional misdeeds, up to and including being able to revoke their medical licenses and board certifications. After all, without a medical license, a physician cannot practice, and without a board certification it is very difficult to practice, as Medicare and Medicaid, as well as most insurance companies require it to reimburse a physician, and most hospitals require it to grant privileges. One has only to consider the example of Texas cancer quack Stanislaw Burzynski, who “discovered” antineoplastons in the early 1970s and has been charging large consultation fees to administer them since the late 1970s to treat cancer patients despite no good evidence that they are effective. Over well over 40 years of having plied his quackery on cancer patients, Dr. Burzynski had managed to avoid significant sanctions from the Texas Medical Board (most recently in 2017) and the FDA for his “clinical trials” that were designed primarily as marketing tools to let him keep using antineoplastons rather than actual clinical trials to determine if antineoplastons work. So it was with great interest that I encountered an op-ed in the New England Journal of Medicine by the President and CEO of the American Board of Internal Medicine (ABIM) Richard J. Baron, MD, and the chair of its board of directors, Yul D. Ejnes, MD, entitled Physicians Spreading Misinformation on Social Media — Do Right and Wrong Answers Still Exist in Medicine? Obviously, I think you know how I (and SBM members) will answer, but first let me start with a little context.

COVID-19: Old quacks revitalized and joined by new quacks spreading disinformation

Burzynski arguably 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.” Basically, the techniques that Burzynski used in the 1990s to pressure the FDA and Texas Medical Board were the same techniques later used to pressure state legislatures and then the US Congress to pass “right-to-try” laws in the name of “medical freedom.” The very same technique is being used to pressure legislatures to promote laws banning COVID-19 vaccine mandates, making repurposed and ineffective treatments like ivermectin available over-the-counter, and immunizing physicians against penalties for using quackery to treat COVID-19.

When the COVID-19 pandemic hit, what we’ve been warning about since 2008 about physicians promoting quackery and misinformation very quickly became a global threat to public health. The usual physician suspects from the past, whom we had long been writing about since back in the day (e.g., Rashid Buttar, Russell Blaylock, Andrew Wakefield, Paul Thomas, Bob Sears, Sherri Tenpenny, Kelly Brogan, various members of old crank medical organizations like the AAPS, etc.), many of whom had been so forgotten that they were largely unknown outside of the deepest, darkest circles of the antivax and quack Internet, soon found themselves becoming relevant—even famous—again, along with the new generation of quacks and cranks who arose to spread COVID-19 misinformation (e.g., Robert “inventor of mRNA vaccines” Malone, Peter McCullough, Simone Gold, Vinay Prasad, Marty Makary, Pierre Kory, Joseph Ladapo, Paul Marik, Vladimir Zelenko, Aaron Kheriaty, and many others). There is now a veritable army of quacks, some of whom are into serious grift (e.g., America’s Frontline Doctors running a prescription mill for ivermectin), but all of whom are spreading dangerous misinformation about COVID-19, vaccines, and unproven treatments for COVID-19 like ivermectin (which to me is now disproven), hydroxychloroquine, and many others, all while doing their damnedest to promote “health freedom,” or, as I like to put it, freedom from professional responsibility, government regulation, or any consequences whatsoever for endangering patients.

Again, this was a problem that SBM had long written about going back to the very beginning of this blog, namely how toothless state medical boards are, 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, a threat to which they have only fitfully been waking up. For example, I noted at the end of 2020 how it had been a year of physicians behaving badly. Before I discuss the NEJM op-ed, I think it’s worth quoting myself from nearly a year and a half ago:

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.

2021 has come and gone, and we’re not far from the halfway point in 2022. What’s happened? The good news is that, as a result of the tsunami of misinformation and disinformation being promoted by physicians, a disturbing number of whom are vaccine-hesitant or outright antivax, nearly a year ago the Federation of State Medical Boards asserted that spreading dangerous medical misinformation could be grounds for a physician’s license to be suspended or revoked, although, unfortunately, the FSMB has not statutory power and all state medical boards are governed by their individual state laws, which have been under assault by “health freedom” antimaskers and antivaxxers not to discipline doctors for spreading COVID-19 misinformation. As I’ve noted before, quacks and antivaxxers targeting state medical boards is nothing new. It’s long been a tactic of antivaxxers and quacks to target state medical boards legislatively, just as advocates for pseudomedical “disciplines” like naturopathy, acupuncture, and the like have long targeted legislators to achieve licensure in more and more states. In the past, it was mostly quack-friendly legislators prodded by powerful pseudomedicine interests. For example, in 2010, the aforementioned Buttar led a successful effort by the North Carolina Integrative Medical Society to persuade legislators to change state law to make it friendlier to practitioners of alternative medicine. Now, North Carolina law prevents its medical board from disciplining a physician for using “non-traditional” or “experimental” treatments unless it can prove they are ineffective or more harmful that prevailing treatments. The same thing is happening today, just on a scale I’ve never seen before.

Other good news is that 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. NFLD has been quite successful since it was formed in garnering press and access to state medical board officials and specialty boards. Unfortunately, much of the rest of medicine has been very resistant to such efforts, apparently viewing them as an unacceptable assault on “freedom.” Indeed, just over the weekend, I saw statements like this about a proposed California law that would empower its medical board to discipline doctors who spread misinformation.

You might remember Physicians for Informed Consent, a virulently antivax physicians’ group.

With that background, let’s look at the NEJM editorial.

The ABIM weighs in…belatedly

It’s hard to argue with the opening of the NEJM op-ed on medical misinformation:

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.

As much as I hate to say, “I told you so,” I told you so, at least we’ve been telling the medical profession, state medical boards, etc., so for over 14 years. None of this is anything new, and SBM has been warning about it since 2008, with some of its member having been warning about it years before. Indeed, one of our bloggers, Val Jones, even coined a term for the attitude of physicians about alternative medicine quackery, medical misinformation, antivaccine pseudoscience, and the like, describing most physicians who didn’t take it seriously as “shruggies”—and she did it in 2008, defining a “shruggie” thusly:

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? As hard as it is to believe, even more than two years into the pandemic and the tsunami of dangerous misinformation and conspiracy theories, there are still a lot of shruggies in the medical profession.

It hasn’t been just social media, either, which largely didn’t exist (at least not at the massive scale it does now) when Steve Novella founded SBM in 2008. The problem had been brewing years before on websites, blogs, Internet discussion forums, Usenet, and old-fashioned email lists. It had also been brewing in our very profession of medicine, with the rise of “complementary and alternative medicine” (CAM), later “rebranded” as “integrative medicine,” which was based on the “integration” of outright quackery into evidence-based medicine. Let’s just put it this way. When there are academic departments in medical schools that promote quackery such as reiki, naturopathy, homeopathy, and even anthroposophic medicine, it’s little wonder that medical academia has been reluctant to confront those in its ranks who promote COVID-19 contrarianism, misinformation, and even outright antivax views.

Baron and Ejnes then 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’s true, too. No one, not even those of us at SBM who have advocated for disciplinary actions that apply to physicians who use their status as trusted professionals to give a patina of science and the authority of medicine to fraud and conspiracy theories, have claimed that there is a bright line between misinformation/disinformation and legitimate differences in scientific and medical opinion. That being said, the ABIM does ask the right question, namely, “Do Right and Wrong Answers Still Exist in Medicine?” I’ll add a spoiler alert by pointing out that the op-ed concludes, “There aren’t always right answers, but some answers are clearly wrong.”

Exactly!

Certainly, at the very least I would agree with Baron and Ejnes that there are indeed answers that are clearly wrong in medicine. They do exist. Cranks and quacks like to wrap themselves in the observation that “medicine changes” as new evidence comes in, all in order to argue that they are doing nothing more than engaging in “debate” and to claim that their views might be vindicated or that they are at least plausible enough not to be immediately dismissed, but such arguments are subterfuge, camouflage to fool the unwary. I also like the example used by Baron and Ejnes, specifically how ABIM certifying exams are constructed specifically the use of “distrators,” answers that are wrong but plausible enough to trap those whose knowledge of the topic is insufficiently deep, although I will argue that it is actually rather simplistic and naive as a comparison to COVID-19 misinformation (and, indeed, medical misinformation and quackery in general):

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.

There’s also quality control in such examinations. If, for example, certain wrong answers are chosen at too high a frequency, the question might be thrown out and modified for or dropped from future versions of the examination. The point, though, is that there are answers that are plausible scientifically, but nonetheless wrong.

There is a huge difference, though, between the example of exam questions and distractors discussed above and the real world misinformation being promoted about COVID-19, a disturbing amount of it by physicians. Specifically, physicians tend to be really good at cherry picking (or even producing) seemingly scientific papers published in the peer-reviewed medical literature to support their misinformation. The problem of misinformation and disinformation is far more complex than there just being no papers to support a particular answer. In addition, physicians can be really good at misrepresenting or distorting 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 not dangerous. In this, I have always thought that Brandolini’s law (also known as the bullshit asymmetry principle), which states that the “amount of energy needed to refute bullshit is an order of magnitude bigger than to produce it,” is far too optimistic. I tend to think that it takes at least two—if not three—orders of magnitude more time and effort to refute bullshit as it does to produce it, and disinformation spreading doctors are very good indeed at producing and repackaging bullshit. Basically, the example used by Baron and Unje is very simplistic and doesn’t recognize the full magnitude of the misinformation problem. It is, however, a start, and 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.

I like that Baron and Unje didn’t just mention false claims about COVID-19 and included one about heart disease. It suggests that maybe—just maybe—they now recognize that the problem of medical misinformation being spread as “health freedom” and the “democratization” of medical knowledge is much broader than COVID-19 and predates the pandemic by decades.

Also, conspiracy theories (e.g., that COVID-19 is a “plandemic” or “casedemic” or that COVID-19 vaccines contain microchips or other tracking devices) should easily fall into this category, as not even being plausible enough to be a distractor in a multiple choice question. I am, however, a bit concerned. Again, there is no bright line between a wrong answer that’s plausible enough to be a “distractor” and bullshit, given the talent a lot of physicians have for cherry picking the scientific literature, and I have to wonder if the experts the ABIM are up to the task of identifying certain claims as implausible. I say this because I saw no mention of the ABIM consulting experts in conspiracy theories and disinformation to adjudicate cases. We’ve documented many times throughout our 14 years of existence how physicians not acquainted with medical misinformation and quackery are often flummoxed when they encounter many of these claims. They just don’t have the background to adjudicate anything in the “gray areas” and sometimes struggle even with cases that to those of us who study quackery and misinformation are obvious cases.

Difficulties aside, I applaud ABIM for starting to grapple with the issue of its diplomates spreading medical misinformation and disinformation, even if they’re late and appear to have a bit of a naive view of what medical misinformation and disinformation are. Basically, I hope that they will learn and suspect that they might have an easier time actually doing something meaningful than many state medical boards will, given the politics in a distressing number of states.

Finally, although it’s the largest, the ABIM is but one of many boards certifying various medical specialties. I, for instance, am certified by the American Board of Surgery, which has not yet stepped up to the plate, and no other board besides ABIM has yet gone as far. Certainly, I hope that a year from now I will no longer be able to say that.