The medical practice of “Lyme literate” guru Daniel Cameron, MD, will be closely supervised by the authorities during a three-year probation imposed last week by the New York State Board for Professional Medical Conduct (BPMC). The order was based on professional misconduct charges filed against Cameron earlier this year.
Cameron agreed to the imposition of sanctions during administrative proceedings on the charges and a consent order was entered by the BPMC based on his concession. He stipulated that
he could not successfully defend against at least one of the acts of misconduct alleged. Those allegations included practicing the profession of medicine with negligence on more than one occasion, incompetence on more than one occasion, gross negligence, gross incompetence, and/or failing to maintain accurate patient medical records.
Who is Daniel Cameron, MD?
Cameron is a solo practitioner in Mt. Kisco, NY, and board certified in internal medicine, but not fellowship-trained in infectious diseases and not board-certified in that sub-specialty. He also holds an MPH and describes himself as epidemiologist. According to his website, he:
is a nationally recognized leader for his expertise in the diagnosis and treatment of Lyme disease and other tick-borne illnesses.
That is partially true. He is a “recognized leader” among those who consider “chronic Lyme” a real disease and who treat it with long-term antibiotics, sometimes for months to years. He is not a “recognized leader” among board-certified infectious diseases doctors and other experts who agree that “chronic Lyme” is not a real disease and who rely on well-conducted trials showing that long-term antibiotics do not substantially improve the outcome for patients diagnosed with so-called “chronic Lyme.” Long-term antibiotics can, in fact, result in serious harm, including death, a subject our good friend Orac covered just yesterday over on Respectful Insolence. The CDC, the Infectious Diseases Society of America (IDSA), the American Academy of Pediatrics, the American College of Physicians, the Medical Letter and the American Academy of Neurology all reject the notion that “chronic Lyme” exists and that long-term antibiotics are an appropriate treatment.
(Orac’s post nicely summarizes the differences between real Lyme disease and “chronic Lyme,” “a prototypical fake medical diagnosis,” and the dangers of long-term antibiotics, as have posts on SBM, here, here, here, and here.)
That has not stopped “Lyme literate” doctors from banding together to form the International Lyme and Associated Diseases Society (ILADS) and issuing their own guidelines for the diagnosis and treatment of “chronic Lyme,” guidelines based on very low levels of evidence that are accepted only by themselves and, in contrast to the IDSA guidelines, no other professional medical organization. ILADS teaches physicians and other practitioners how to become “Lyme literate,” although there is precious little information about the courses on the ILADS website. ILADS, again in contrast to IDSA, is not an ACCME-accredited provider of continuing medical education and, to my knowledge, none of its courses qualify for continuing medical education credit. Nor are ILADS guidelines taught as appropriate in any medical school, residency or fellowship program.
Unfortunately, according to Cameron,
ILADS healthcare providers currently serve more than 100,000 patients with Lyme and associated tick-borne diseases in the USA and around the world.
Cameron is a leading light among the “Lyme literate.” He is the past president of ILADS and is the lead author of both the original ILADS guidelines and its 2014 update. He has testified before several state legislatures promoting the protection of “Lyme literate” doctors from prosecution by state medical boards, including the legislature in New York, where such a bill became law. He also makes presentations to Lyme support groups, spreading the gospel of “chronic Lyme.”
He has written a number of articles in the medical literature promoting the notion that “chronic Lyme” exists and that long-term antibiotics are an appropriate treatment, including two in the bottom-feeder journal, Medical Hypotheses, known for its publication of pseudoscientific papers.
His bibliography includes a letter to the editor of the New England Journal of Medicine, complaining about an article by infectious diseases experts rejecting “chronic Lyme” as a valid diagnosis and its “treatment” with long-term antibiotics. The evidence, Cameron claimed, is actually in “clinical equipoise.” This drew a sharp rebuke from the article’s authors:
The term ‘clinical equipoise,’ used by Cameron, is difficult to justify in view of the published reports of five double-blind, randomized, placebo-controlled clinical trials that have convincingly demonstrated that antibiotic treatment of post–Lyme disease symptoms is not in the best interests of patients. Our article summarizes the consensus among clinicians who practice evidence-based medicine . . .
The direct implication being, of course, that Cameron is not one “among clinicians who practice evidence-based medicine.”
Only by airing these different points of view will the medical and scientific community reach a better understanding of controversial topics such as treatment of chronic Lyme disease. Meanwhile, physicians must be able to exercise their clinical judgment and patients should be provided with treatment options.
With that, let’s turn to how, in the view of the New York state medical authorities, Cameron exercised his “clinical judgment” and provided patients with “treatment options.”
“Clinical judgment” and “treatment options”
Apparently, New York’s medical misconduct procedures do not require the physician charged to stipulate to any particular acts of misconduct as a condition of settling his case. Rather, as noted, Cameron simply stated he was unable to “successfully defend against at least one of the acts of misconduct alleged” and agreed to the imposition of sanctions. This means the allegations in the state’s Statement of Charges were never proven, as it was unnecessary to reach a decision on the factual issues once Cameron decided to settle. However, per the Office of Professional Medical Conduct’s (OPMC) standard procedures, the allegations in the Statement of Charges were based on expert review of Cameron’s patients’ records and they remain uncontested by Cameron.
The state’s allegations were based on Cameron’s care of seven patients. According to the Statement of Charges, some of his more egregious actions include:
- Continuing to prescribe narcotics to a patient diagnosed with bipolar disorder and narcotic abuse for two years after the patient had moved to another state.
- Failing to follow up on previous diagnostic tests and symptoms indicative of multiple sclerosis, “thereby depriving the patient of an accurate diagnosis and years of effective therapy for her progressive disease.”
- Failing to appropriately and timely evaluate a patient, who suffered from Parkinson’s disease, when she complained of pain associated with a PICC line inserted at Cameron’s direction for parenteral antibiotics, which itself was done without an appropriate physical examination or “clinical re-assessments for consideration of any alternative diagnoses and/or treatment.”
- Failing to consider “other infections or inflammatory processes” in a patient with a recent termination of pregnancy and diverticulitis, who had abnormal lab results, including abnormal liver function tests and an elevated sedimentation rate, and failure to order a CT scan of the abdomen and pelvis as well as additional blood testing.
The state wisely avoided specifically challenging Cameron’s diagnosis of his patients with “chronic Lyme” or his treating “chronic Lyme” with long-term antibiotics. In fact, the term is never mentioned. In doing so, it circumvented the quagmire of arguing over “different points of view” and concentrated on the fact that Cameron quite simply failed his patients by giving them substandard care, “chronic Lyme” or no “chronic Lyme.” This strategy also avoided any shield which might have been provided by New York’s foolish law aimed at protecting “Lyme literate” doctors.
Yet the fingerprints of “chronic Lyme” diagnosis and treatment show through loud and clear in the state’s case. For each and every patient, Cameron was charged with:
- Repeatedly failing to take and/or note an adequate history of present illness.
- Repeatedly failing to perform and/or note an appropriate physical examination.
- Failing to appropriately construct a differential diagnosis and pursue a through diagnostic evaluation.
- Failing to maintain records accurately reflecting care and treatment rendered to the patient.
For six of the seven, he was charged with:
Treating patients inappropriately with an ongoing and escalating antibiotic regimen without appropriate sequential physical examinations and clinical reassessments for consideration of any alternative diagnoses and/or treatment.
And for four of them, according to the state, Cameron failed to follow up in a timely fashion when the patient developed possible adverse reactions to therapy.
Two of the patients who presented with complaints of fatigue and pain had previous diagnoses and treatment for Lyme disease, 9 and 16 years earlier, fitting the “Lyme literate” notion that their current complaints are most certainly sequelae to inadequately-treated Lyme and cannot be attributed to other causes.
Reading between the lines, Cameron had only one tool, a hammer, so he saw every problem as a nail. The possibility that the patient might be suffering from something other than “chronic Lyme” was tossed aside via inadequate physical exams and medical records, failing to consider other diagnoses, and bulldozing ahead with inappropriate long-term antibiotics, adverse consequences be damned.
Of course, if you think about it, substandard care and “Lyme literacy” would appear to go hand-in-hand. It is hard to imagine the “Lyme literate” doctor, who routinely ignores medical science in favor of unvalidated testing, makes repeated diagnoses of a fake disease, and orders unwarranted long-term antibiotics, otherwise delivering standard-of-care medical practice. As with the Cameron case, this offers a way forward to state medical boards hamstrung by laws designed to protect the misconduct that is “chronic Lyme” from disciplinary action.
Terms of three-year probation
In entering into his probationary period, Cameron is in the company of other “Lyme literate” doctors who have had their medical practices questioned by their peers, up to and including discipline imposed by medical regulators (also, here and here).
Hopefully, Cameron will be hard-pressed to continue his usual M.O. under the terms of the Board’s Consent Order. He has agreed to practice medicine only when monitored by a licensed physician (a “practice monitor”) who must be “board certified in an appropriate specialty considering [Cameron’s] specialty of practice, who is familiar with the diagnostic and treatment modalities practiced and offered by [him].”
The practice monitor can see all of Cameron’s records and must visit his office “on a random unannounced basis at least monthly” and examine no fewer than 20 records. The monitor’s review is to determine whether Cameron’s medical practice “is prudent and competent.” Any perceived deviation from prudent care or refusal to cooperate must be reported to the OPMC within 24 hours. The monitor must also report to the OPMC quarterly and Cameron must pay the expenses of monitoring.
Cameron gets to propose his own monitor to the OPMC. This, coupled with the language about familiarity with Cameron’s “diagnostic and treatment modalities,” leaves some concern that a fellow traveler would be put in charge. The fact that the OPMC must approve the monitor, plus the broad authority given to the OPMC in the Consent Order to look at his records and otherwise investigate what he is up to, somewhat allays those concerns.
He must also, among other things:
- Obtain written informed consent from each patient “specifically addressing all aspects of treatment” and provide the OPMC with copies of his consent forms.
- Fully document all discussions with patients concerning his evaluation and treatment “and of the patient’s need to pursue conventional medical care elsewhere, if indicated.” This is of some concern as well, as it implies Cameron is free to provide unconventional medical care as long as he tells the patient she needs the conventional kind.
- Obtain and review medical records from physicians who previously or are currently treating his patients and refer patients to other physicians for further evaluation and treatment “where medically warranted and beyond the scope of [Cameron’s] role with regard to the patient.”
- Maintain at least $2 million per occurrence/$6 million per policy year limit medical malpractice insurance.
- Complete CME courses as directed by OPMC.
But, Legislative Alchemy
Whether Cameron’s case will prove to be a cautionary tale for other “Lyme literate” doctors remains to be seen. Even as one branch of state government successfully prosecutes a “Lyme literate” doctor, another branch, the legislature, is considering forcing insurers to cover treatment of “chronic Lyme,” the subject of no less than three bills now pending. (Assembly Bill 114, Senate Bill 4713, Senate Bill 670). Three other bills are sympathetic to the cause in that they will give “chronic Lyme” advocates yet another venue to argue for insurance coverage. (Assembly Bill 4863, Senate Bill 2168, Assembly Bill 6927). Pseudoscience, it seems, is endemic in the state of New York.