Board certification in family medicine and "integrative" medicine: different standards of care?

Board certification in family medicine and “integrative” medicine: different standards of care?

Florida Atlantic University student Stephanie Sofronsky was diagnosed with Hodgkin’s lymphoma in 2011, after review of her case by oncologists and pathologists at Moffitt Cancer Center in Tampa, the NIH/National Cancer Institute, and the Mayo Clinic in Jacksonville. By June of that year, a PET scan showed the cancer had progressed to her pelvic region. She decided to be treated locally by oncologist Neal Rothschild, MD, and met with him to discuss chemotherapy and ongoing management of her cancer. At this point, with Stage III Hodgkin’s lymphoma, she had an 80-85% chance of being in complete remission with appropriate treatment.

Unfortunately, at the same time, Sofronsky was also seeing Kenneth Woliner, MD, a family medicine practitioner. Despite the fact that world-renowned cancer specialists agreed that Sofronsky had Hodgkin’s lymphoma, and knowing that she was about to start chemotherapy, Dr. Woliner told Sofronsky that cancer was “low on his list” of possible medical concerns and that increased lymphoctyes shown in her tests were not indicative of cancer, insinuating that oncologists “often overreact” to the presence of lymphocytes and recommend chemotherapy before making an actual diagnosis. Dr. Woliner suggested instead that Sofronsky have her house tested for mold, which could be causing allergies, and therefore her symptoms. Convinced, Sofronsky pursued treatment for her allergies and cancelled her follow-up appointment with Dr. Rothschild.

Sofronsky complained repeatedly to Dr. Woliner of symptoms that were, as our good friend Orac points out, consistent with progressing lymphoma – back pain and pain and swelling in her lymph nodes, abdomen and legs, to the point of having to use a cane. Yet, Dr. Woliner, over the next couple of years, continued to attribute her symptoms mostly to her allergies and also thyroid issues and some other minor illnesses. On February 7, 2013, at her last visit to his office and in significant distress from pain and severe leg swelling, he ordered a 100 mg shot of iron, despite the fact that her blood tests showed she was not iron deficient. She rapidly decompensated and died in the hospital three days later of from complications of untreated Hodgkin’s lymphoma.

In 2015, the Florida Department of Health filed a complaint against Dr. Woliner alleging medical malpractice, failure to keep legible medical records, exploiting a patient for financial gain, and accepting or performing the professional responsibilities of an oncologist that he knew, or should know, he was not competent to perform. A hearing was held before an Administrative Law Judge (ALJ) in February of this year. The ALJ issued a Recommended Order in April, and, based on the facts she found, some of which I’ve set out above, she concluded:

  • Dr. Woliner fell below the standard of care in treating Sofronsky, by failing to timely refer her to an oncologist, educating and counseling her on the risks, including death, of not treating her cancer, and by failing to appropriately attribute her symptoms to her lymphoma.
  • He failed to keep legible medical records providing an adequate medical justification for his diagnoses and treatments.
  • He exercised influence over his patient in such a manner as to exploit her for financial gain by scheduling appointments, selling and administering drugs, and obtaining blood work when he knew or should know that none of these would reasonably alter her medical condition, treatment or life expectancy.
  • He practiced beyond the scope permitted by law by minimizing, if not outright rejecting, Sofronsky’s diagnosis of Hodgkin’s lymphoma, because he is not an oncologist nor was he qualified to give any advice regarding treatment of her cancer.

The ALJ recommends that his medical license be revoked, a $16,000 fine, and repayment of the money Sofronsky paid him to her estate as well as the state’s costs of prosecuting the case. The Florida Board of Medicine will make the final decision, although it has very limited legal authority to reject the ALJ’s findings of fact. It can, however, independently decide all legal issues, including the penalties.

The standard of care for “integrative” medicine, if any?

Given my interest in the intersection of science-based medicine and the law (or, more usually, the lack of intersection), I find one of the defenses presented by Dr. Woliner particularly fascinating. He argues that, even though he is Board-Certified in family practice, he is an “integrative” physician and, as such, is not held to the same standard of care as a “conventional” doctor.

And integrative he is. Dr. Woliner’s website, which advertises his board certification in family practice and calls itself “Holistic Family Practice,” also notes he is Board Certified in Integrative Medicine, certified by the American Board of Integrative Holistic Medicine, and certified in Functional Medicine. He sells patients Metagenics-brand dietary supplements and his website has an online store. His specialty list includes candida, thyroid conditions (even though he is not an endocrinologist or an ENT), food allergies (even though he is not an allergist) and “bioidentical hormones” (a marketing, not a medical, term). If you click on any of these headings expecting to find more information on the topic, you won’t. Instead, you’ll find anecdotes describing cases in which Dr. Woliner was able to figure out what was really wrong with the patient and how he successfully treated that condition, usually after other doctors had failed.

Woliner’s charming anecdotes are a perfect lesson in how unsuccessful cases are excluded from testimonials, one reason they are worthless as evidence of safety and effectiveness.

I imagine he won’t be adding the Sofronsky case to his list. You’ll also not find, under “Thyroid Conditions,” his 2005 settlement with the Board of Medicine, in which he admitted he had, among other things:

  • diagnosed a patient with Hashimoto’s thyroiditis who had no indication thereof clinically or biochemically,
  • diagnosed the patient with adrenal insufficiency who showed no biochemical indication,
  • overdosed the patient on thyroid medication, making him hyperthyroid, and
  • failed to consult with an endocrinologist instead of “treating conditions that did not exist.”

Ironically, as part of his settlement with the Board, he was required to take a course on keeping adequate medical records.

The Department of Health presented two expert witnesses at the hearing. One, an oncologist, testified to the scope of practice of oncology, which was necessary to establish that Dr. Woliner practiced outside of his, whether it be family practice or integrative medicine. The other, a board-certified family practice doctor, testified to the standard of care for that specialty, and that Dr. Woliner fell below it.

Dr. Woliner argues that neither expert’s testimony should be admitted because, as an integrative physician, only a “qualified” integrative physician can testify to the appropriate standard of care. For Dr. Woliner, that expert is Stephen Silver, MD, a Boca Raton doctor, who, interestingly, does not claim on his website (“HealthSmart MD: Private Family Medicine and Medi-Spa”) that he is an integrative specialist and actually says he follows the same standard of care as the traditional medical community. However, he does offer, among other services, “anti-aging” medicine, IV vitamins, and medical astrology. As he, um, explains,

Astrological Medical and Psychological constitution are determined at birth, affording a skilled Medical Astrologer a valuable tool when diagnosing and treating patients. . . . A Natal Chart is constructed utilizing your birthday, birth time (call mom) and birth location. Astrological Philosophy states that each soul incarnates at a precise time and in a precise place to best predispose the native to fulfill his/her life purpose. This chart describes in accurate detail the twelve (12) spheres of mundane (earth) life and your basic drives and motivations in these areas . . . I use the natal chart as invaluable tool to better understand myself, my patients and the energy flow between people. I am delighted to perform an Astrological chart analysis and profile upon request . . . The Astrological Signs and Planets are correlated with the anatomy, physiology and disease potential of the human body and provide an excellent basis for “Energy Medicine”.

Because, when your medical license is at stake and you need an expert to testify on the standard of care for integrative medicine, you call only the best. I wonder what the standard of care is for medical astrology?

Unfortunately, while the transcript of the hearing and many other documents are available online (although excruciatingly hard to find; hint: see pages 8900-10592) from the Board of Medicine, Dr. Silver’s testimony (submitted by deposition) is not included for reasons that are unclear. However, from the ALJ’s Recommended Order we learn that Dr. Silver opined Dr. Woliner’s role was that of an out-of-network, adjunct holistic doctor,

more comparable to an acupuncturist or a Reiki specialist than a medical doctor . . . [and] suggested that Respondent should not be held to the same standard of as other family medicine doctors providing primary care services.

In other words, an integrative physician has no duty to refer a patient with cancer to an oncologist, no duty to explain to her the grave consequences of her decision to forego chemotherapy, no duty to correctly attribute her symptoms to Hodgkin’s lymphoma. Doesn’t say much for integrative medicine doctors, does it?

The ALJ ultimately rejected Dr. Silver’s assertion that a different standard of care should apply, as well as Dr. Woliner’s claim that he wasn’t acting as Sofronsky’s PCP, which she found “specious.” In response to Dr. Woliner taking exception to the ALJ’s determination, the Department of Health notes, correctly, that Dr. Silver never said what this purportedly different standard actually was.

It is ironic that a physician with Dr. Woliner’s disdain for “conventional” medicine would argue that he is somehow held to a lower standard of care than a conventional physician. (I realize he doesn’t explicitly argue that the standard is lower, but that is in essence what he is saying.) Here’s what he has to say about you “traditional” doctors in an issue of Aventura, a local “lifestyle” magazine:

What is different about holistic medicine from traditional medicine?
Holistic medicine requires the assessment of the whole person, body, mind and spirit, in the quest for optimal health and wellness. While traditional allopathic medicine often relies on looking at individual symptoms and covering up those symptoms with prescription drugs, a holistic approach looks for functional imbalances and seeks to treat the underlying causes of illness.

As Harriet Hall, MD, said, “this stupid CAM mantra is a vile, false accusation,” and it is a dangerous one too. Dr. Woliner’s smug attitude about “conventional” medicine led him in both this case and his previous run-in with the Board of Medicine to reject the superior education and training of specialists in two complex fields, oncology and endocrinology, in favor of his own supposed expertise as an “integrative” physician. He even used the “if the only tool you have is a hammer” analogy with Sofronsky’s mom when describing oncologists. Yet, he was so blinded by that pet all-purpose bugaboo of integrative medicine – allergies – that he kept insisting that her obvious symptoms of spreading cancer were caused by them.

Not a different standard – a lower standard

Integrative medicine gives a physician permission to lower the standard for evidence of safety and effectiveness. After all, alternative medicine that’s been proven to work is just medicine. But, it is not only in their employment of quackery that integrative physicians are a menace to patients, it is this disdain for conventional medicine too. That disdain came through loud and clear in Dr. Woliner’s testimony, where he defined “mainstream medicine” as “patentable drugs and surgery.”

In one final, sad irony, here’s what Dr. Woliner says on his website about “the ideal candidate for holistic medicine”

Anyone who is interested in actually fixing the cause of their medical problems, rather than merely attempting to cover up symptoms, is the ideal candidate for holistic medicine.

Chemotherapy had a great chance of “fixing” Sofronsky’s “medical problems” but that chance was squandered on “holistic medicine.” I hope the Board of Medicine accepts the ALJ’s recommended penalty and revokes Kenneth Woliner’s medical license. He shouldn’t get a third chance to choose arrogance over “conventional” medical treatment for his patients.
 
 

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.