Why are physicians threatened by efforts to report doctors to their state medical board for COVID-19 misinformation?

We at SBM have long lamented how physicians can practice quackery and promote pseudoscience while spreading medical conspiracy theories and only rarely do state medical boards do anything concrete to stop them. Indeed, so uncommon is it for a state medical board to suspend or revoke the license of even the worst quacks that, when a quack does suffer sanctions from his state medical board, we tend to write about it here. Examples include when Florida revoked the license of a “Lyme literate” doctor and New York sanctioned other promoters of the fake diagnosis that is “chronic Lyme disease“. (Of note, one of those New York doctors sued Jann Bellamy and the editors of SBM, also naming some of us who had long ago left or retired from this blog, for having written about him.) Surprisingly to me, even pediatricians and other doctors who are leaders of the antivaccine movement have largely escaped discipline from their state medical boards, to the point that it is noteworthy when they are actually disciplined, with the example of Dr. Bob Sears and Dr. Paul Thomas coming to mind.

Counterexamples also come to mind, such as Dr. Rashid Buttar, who treated autistic children and cancer patients with chelation therapy and referred to the North Carolina Medical Board as a “rabid dog“. Two years later, he was free to practice again (mostly) unencumbered, having signed a consent decree with the Board that reprimanded him and ordered him (1) to provide informed consent to his patients as dictated by the Board; (2) to obey all laws, as well as rules and regulations governing the practice of medicine in North Carolina; (3) to notify the Board if he changes his address; and (4) to meet with the board periodically. And don’t even get me started on cancer quack Dr. Stanislaw Burzynski, who has been treating patients with his ineffective “antineoplastons” for 45 years now, with at least three attempts by the Texas Medical Board failing to stop the harm, the most recent attempt ending with a consent decree in 2017 after four years. Meanwhile, doctors peddling COVID-19 misinformation, such as Dr. Lee Merritt, COVID-19 quack Dr. Simone Gold, and long-time antivax “leader” Dr. Sherri Tenpenny, are easily renewing their medical licenses. (Tenpenny has long referred to vaccines as a method of “mass destruction” and “depopulation” and more recently actually claimed that COVID-19 vaccines make you magnetic, if you remember that gem from last year.) Worse, COVID-19 denying and quackery-friendly legislators are trying to hamstring state medical boards.

In the months after the pandemic first hit in 2020, many of my colleagues were shocked to see the number of physicians promoting outright misinformation and even antivaccine quackery about COVID-19. They shouldn’t have been. This was completely foreseeable if only they had been paying attention. So was the shock expressed by colleagues that, for example, America’s Frontline Doctors (the ones pushing hydroxychloroquine in 2020 and ivermectin last year whose number included the infamous “demon sperm” doctor) didn’t suffer any consequences. Quite the opposite, in fact. One of them, Dr. Joseph Ladapo, was nominated to take charge of the public health bureaucracy in Florida, where he is now implementing all manner of unscientific and dangerous COVID-19 policies. That’s why I was heartened to see colleagues wake up to the threat of misinformation and the promotion of quackery, as manifested by the formation of No License for Disinformation, founded by Dr. Nick Sawyer and colleagues, whose goal is to change the current situation, in which doctors promoting COVID-19-related disinformation have faced virtually no consequences so far. Of course, I have argued that NLFD doesn’t go far enough and that this effort shouldn’t be primarily restricted to just COVID-19 misinformation and quackery, but do welcome the baby steps towards a more general effort to hold quacks accountable.

You’d think that the vast majority of doctors would approve of a renewed effort to purge our profession of dangerous doctors practicing COVID-19 quackery and promoting harmful misinformation. I like to hope that you’d be right, but lately I’ve been seeing a number of doctors who are very disturbed by NLFD and have been expressing their unease in op-eds and on social media. I’ve been seeing more and more of this after a Maine physician named Dr. Meryl Nass had her license suspended for promoting COVID-19 disinformation, although certainly there are doctors who agree with me:

There were others who were—shall we say?—much less enthusiastic about this development. Why is this? Why are some doctors so uncomfortable over the idea of state medical boards sanctioning doctors who promote COVID-19 disinformation? Doctors, after all, hold a special high status in society. Because of our medical expertise, physicians’ medical credentials lend credence to their pronouncements and, when physicians promote pseudoscience and quackery, their assumed expertise is trusted by much of the public.

“Cancel culture” vs. quality control

So what do I mean by doctors who come across as threatened by an effort to hold COVID-19 disinformation-promoting doctors accountable? Of course, there were predictable responses like this from non-physicians, which were easy to dismiss:

I do so love how conspiracy theorists love to claim that every conspiracy was a “conspiracy theory” that was later shown to be correct. One key difference between conspiracies and conspiracy theories is that conspiracies have strong evidence to support that there was an actual conspiracy.

There were, however, reactions like this from doctors:

To be honest, I wasn’t sure what Dr. Jha’s point about this was. Moral arguments can be just as misleading if they use pseudoscience, conspiracy theories, and quackery to support them. In any event, Dr. Jonathan Howard and I responded:

Doctors who promote misinformation have long hidden behind the First Amendment and “free speech” dating back to long before the pandemic. One prominent example includes the Association of American Physicians and Surgeons (AAPS), which is, in essence, a medical John Birch Society camouflaged as a legitimate medical professional society. I’ve written about the AAPS a number of times, relating how it’s promoted antivaccine pseudoscience blaming vaccines for autism, including a view that is extreme even among antivaccine activists, namely that the “shaken baby syndrome” is a “misdiagnosis” for vaccine injury. It’s worse than that, though. AAPS has promoted HIV/AIDS denialism, blamed immigrants for crime and disease, promoted the pseudoscience claiming that abortion causes breast cancer using some of the most execrable “science” ever, and not only rejected evidence-based guidelines as an unacceptable affront on the godlike autonomy of physicians; the very concept of a scientific consensus about anything. Indeed, in August an AAPS member likened the recent statement by the Federation of State Medical Boards (FSMB) endorsing disciplining doctors for spreading COVID-19 misinformation to the Soviet NKVD, which led me to quip that at least he didn’t invoke Nazis.

I mention the AAPS for two reasons, first to contrast it with the doctors expressing extreme reserve about NLFD and second to disabuse readers of the concept that there aren’t a lot of crank MDs and DOs. It’s easy to make fun of the AAPS, because it is truly a home for little but medical conspiracy theorist “brave maverick doctors” who “don’t follow the herd” even when the herd is actually correct, hence the antivax and HIV/AIDS denial that has flowed from it. However, the doctors expressing reservations most assuredly are not cranks. (Although I didn’t recall ever having interacted with Dr. Daly before, I actually rather like Dr. Jha.)

What is interesting is why doctors who practice science-based medicine would react negatively, to the point of unironically echoing the whole “cancel culture” talking point, leading to a continuation of the conversation:

Actually, “Mr. Bond” makes an excellent point that echoes what we at SBM have been saying for a long time.

Then there was this:

A flippant response would be to ask: If state medical boards can’t be tasked at determining what is quackery and misinformation, then who can? The response, though, isn’t so flippant if you think about it, particularly in the context of my periodic laments over the last two decades over how state medical boards so rarely ever actually discipline outright quacks like Dr. Buttar or Burzynski. And if state medical boards can’t enforce even a minimal standard of professional behavior, both in terms of treating patients and public health messaging by licensed doctors, then what good are they? Sure, getting rid of doctors who are impaired due to substance abuse disorders, who assault patients, or who defraud third party payers and patients is good and necessary, but it’s not sufficient, nor is it “cancel culture” for state medical boards to sanction misinformation-spewing physicians.

Let’s take a look at the common concerns expressed by non-quack physicians about NFLD.

Start with an “easy” example

In considering the whole issue of “cancel culture” and physicians’ reactions to Dr. Nass’ suspension by Maine, let’s start with the article that Dr. Jha cited, “Physicians React: Should Docs Lose Their Licenses for Spreading False COVID Information?” The article breaks down physician responses on social media into two categories, Yes, Those Doctors Are Doing Wrong and No, Those Physicians Have a Right to Speak Their Beliefs. Since I am arguing the first point, I’ll be focusing more on the arguments for the second, most of which boil down to a fear that “science and controversial thought” were being “muzzled.” Interestingly, these sorts of arguments came from perspectives that could be considered both right and left wing. For example, here’s one who based opposition on distrust of big pharma:

Another clinician claimed the “truth is very difficult to discern from less-than-truth in a country running on a profit-oriented economic ideology.”

While, from the other side:

“Who can determine exactly what is truth?” asked another clinician. “For sure, the ‘Federal Government,’ who ‘is here to help you,’ is not qualified to make such determinations, and who are you to make such a suggestion as to remove someone’s license because they disagree with you. Give me a break!”

“What is truth?” How, very, very deep! (Really, most doctors are pretty crappy at philosophy.)

While it is true that big pharma doesn’t have the greatest track record in terms of its messaging, it does not follow from that history that it is impossible to discern good science from bad or quackery from science-based medical care, nor do past errors by the federal government imply the same thing. Similarly, it is the state governments who set up state medical boards, which are made up of physicians and stakeholders from the public, and no one—no one—is saying that the federal government (or a state government) should take away a physician license.

This is where my “easy example” comes in, specifically naming physicians who deny germ theory and use that denial to spread antivax misinformation, something I did last week on Twitter:

This, of course, is an “easy example” if you don’t overthink it. I’m not talking about, for instance, the relative contribution of host susceptibility versus the microbe to the development and severity of disease. I’m talking about the very basic concept of whether “germs” cause disease at all, the denial of which is a longstanding belief in large swaths of alternative medicine and the antivaccine pseudoscience spawned by it. I’m talking about people like Dr. Kelly Brogan:

We at SBM have written about Dr. Brogan before. Recall that she was denying germ theory years before the pandemic. Unsurprisingly, she continues to deny germ theory when it comes to COVID-19. As I’ve said many times before, if there’s one thing that those of us who have been struggling to counter medical misinformation, quackery, and antivaccine pseudoscience frequently encounter, it’s medical professionals and scientists who have a hard time believing us when we describe just how unscientific, pseudoscientific, and just plain conspiracy-addled various beliefs underlying alternative medicine and antivaccine pseudoscience are. Surely, they seem to think, there’s no way anyone could actually believe that in 2022! How wrong they are, and among the alternative medicine beliefs that provoke the most disbelief among my colleagues (and among educated lay people) is germ theory denial. Few doctors believe me when I say there are people (and doctors) who deny basic germ theory. I have to show them the evidence.

Generally, most physicians expressing discomfort over medical board sanctions for spreading health misinformation will agree that a physician like Kelly Brogan, who denies basic germ theory, should face sanctions from her state medical board. Certainly Dr. Daly did. Therein lies the trap. By conceding that promoting one very obvious sort of medical misinformation should be sanctionable by a state medical board, the naysayers concede my main point, that state medical boards should have the power to sanction physicians who promote misinformation. The rest is just “haggling over the price” (to echo a famous joke); i.e., determining what specific sorts of misinformation should be sanctionable.

That’s when these doctors usually retreat into complaining that “dogma will prevail” if sanctioning doctors on the basis of their spreading misinformation becomes widespread. Then, even as they concede that misinformation coming from doctors can be dangerous, they won’t take a stand on where to draw the line, leading to exchanges like this:

Notably, Dr. Ryan never answered Mr. Bedell’s very reasonable question about real world examples. Presumably he does not support sanctioning speech promoting conspiracy theories like that, but maybe I’m wrong. He never answered the question. Those of us who are trying to fight disinformation do not have the privilege and liberty of not taking stands on these questions. No one is saying that these questions are easy in general, but sometimes they are. Kelly Brogan and physicians who deny germ theory are not difficult cases, at least conceptually. I concede that implementing standards for misinformation that rises to the level of being dangerous is not easy.

“Settled science,” Or “What about scientific debate?”

Another common complaint by physicians over the move to sanction doctors promoting misinformation is that no science is “settled” and that such sanctioning will somehow inhibit “scientific debate”. For instance, here’s an example from the Medscape article:

However, many physicians worried that science and controversial thought were being muzzled.

“Absolutely no,” a doctor stated. “Who judges what is misinformation in this age where debate is canceled? Science advances with challenge and it’s not about an authority dictating the allowable opinion.”

Again, I also quote Dr. Daly, who asks the questions:

And appeals to the “art” of medicine:

This is, of course, a very common straw man fallacy frequently invoked whenever professional and scientific sanctions against physicians spreading misinformation are advocated. Here are a couple of more examples from the Medscape article:

One specialist warned that if disinformation doctors are held responsible, then “that means a lot of doctors” will be “gone” because “almost anything that is written or said about COVID can be contested.”

Another physician warned his colleagues about suppressing new ideas: “To condemn what we didn’t try, or purposefully ignore a different approach because [it] doesn’t agree with our opinion is suppression of information.”

Here we go again with “What is truth?”

My response is simple. No one is suggesting, much less arguing, that “all science is settled” or that state medical boards should strip doctors of their medical licenses for taking medical or scientific positions that are reasonably debatable from a scientific standpoint. Certainly, I’ve never made that claim, nor have I argued anything like this. I do, however, argue that there are certain scientific conclusions in medicine that are as close to being “settled” as one can imagine, to the point that not accepting them is unscientific quackery. Basic germ theory is one. That homeopathy is physically impossible is another. As I like to say about homeopathy, for homeopathy even to have a chance of working would require not just that huge swaths of very well-established theory in physics and chemistry be wrong, but that they be spectacularly wrong. Another way of putting it is that to provide sufficient evidence to make homeopathy physically plausible would require a level of evidence that can topple major theories undergirding our current understanding of chemistry and physics. I generally conclude by saying that all theories are “challengeable”, but that simply denying them based on no evidence (or on highly dubious “evidence” and conspiracy theories) is not a “challenge” that professional societies and medical boards are obligated to take seriously as “scientific debate”.

Similarly, just because the science of COVID1-19 is rapidly evolving, having started out with us knowing little about the coronavirus, its mechanism of activity, its transmissibility, and the like, contrary to the claim that “almost anything that is written or said about COVID can be contested”, it’s not as though we know nothing about it. Even in the early days of the pandemic we knew a lot about coronaviruses, of which SARS-CoV-2, the coronavirus that causes COVID-19, was a novel example. For example, as early as January 2020, I could say with a great deal of confidence that SARS-CoV-2 was not a result of a vaccination campaign in China against the flu vaccine.

To sum it up, rapidly evolving science and a lack of knowledge do not mean no knowledge or that we cannot with a high degree of certainty know what is not true or recognized science denial and conspiracy theories when we see them. It doesn’t mean we can’t know quackery when we see it. Moreover, it’s now nearly two years since the pandemic hit the US. The “fog of war” argument about the lack of scientific knowledge regarding COVID-19 and SARS-CoV-2 is much less compelling now than it might have been in March 2020.

Aside from that, doctors also often express fears that such sanctions will shut down “nuance”:

Here’s the problem. We are not dealing with “nuance,” and the fallacy that we are talking about here is not anything resembling “scientific debate”. It’s denialism. On a conceptual level, it’s no different than the denial of, for example, climate science, evolution, or that HIV causes AIDS. Indeed, germ theory denial is a form of denialism, as is antivaccinationism. Physicians who express concern that holding physicians who are promoting denialism to account will somehow shut down scientific debate are doing exactly what brothers Mark and Chris Hoofnagle warned about years ago, mistaking denialism for debate. It’s exactly the trap that disinformation peddlers want you to fall into. Denialism generally involves at least more than one of five things: conspiracy theories, fake experts, cherry picked evidence, impossible expectations (and moving goalposts), and, of course, logical fallacies.

Speaking of logical fallacies…

“It’s a slippery slope”

Another oft-expressed concern is that if state medical boards start sanctioning doctors promoting COVID-19 misinformation, it’ll be a slippery slope to their sanctioning all sorts of other things. In other words, they express fear that “gray areas” will end up being sanctioned. Examples include (and I don’t mean to keep picking on Dr. Daly, who seems sincere and dedicated to evidence-based medicine, but he sums up the common arguments rather succinctly). Here’s another invocation of the “slippery slope”:

And:

Again, no one claims that this is an all-or-none argument. I’ll also point out that, contrary to what some argue, a slippery slope argument is not always a logical fallacy, conceding that there can be occasional valid uses of it. The are, however rare, and I agree that is it almost always a logical fallacy that avoids the specific question at hand and instead distracts with extreme hypotheticals, all without any evidence that the action proposed will lead to the chain reaction suggested, ultimately resulting in the undesirable consequences proposed, which become increasingly improbable the farther along the chain reaction of consequences one drifts. It’s an appeal to fear, not reason.

At its essence, the slippery slope argument, whether the person deploying it realizes it or not, is always an argument to do nothing, based on invoking the fear of some inevitable awful consequence somewhere down the line if a first step is taken.

This wasn’t a doctor who said this, but it is a more extreme example of what I’m talking about:

And:

None of the doctors that I encountered went as far as putting Nazi Germany or the Gulags at the end of their slippery slope, but at their core their arguments were not far removed from this.

Whataboutism

The final sort of argument that I’ve seen involves something known as “whataboutism” or “whataboutery”. In brief, whataboutism is a logical fallacy and rhetorical technique of distraction in which a person responds to a criticism with a counter-accusation in order to divert attention to a different topic. The origin of the term goes back to the Cold War, where it was coined to describe the oft-used technique by the Soviet Union to counter various charges made against it. The following is a classic example:

One clinician suggested enforcement against health food, drug company commercials, and talk shows: “What about all the [misinformation] at the health food stores and the like. Doctors of natural-whatever? Those info-commercials on tv. How many faxes do I get to ‘approve’ because ‘patients request’ braces and pain-treating expensive compounds advertised on TV? We tolerate those…. What about Dr Oz and the docs on talk shows claiming BS?”

This bit of whataboutism is not nearly the “gotcha” that physicians (and others) making this argument think it is, at least not to me. I’ve been arguing to do something about all of these things for a very long time, as has everyone here at SBM. Need I remind you how often we have written about the licensure of quacks, Dr. Oz, and quackery in pharmacies? And that’s just a small sample.

State medical boards vs. COVID-19 (and other) misinformation

State medical boards are in a difficult situation that has only become more so with the rise of quacks promoting COVID-19 misinformation. I’ve long lamented how reluctant they are to discipline doctors practicing quackery and promoting antivaccine conspiracy theories and other dangerous misinformation, even before the pandemic. It was a problem that few seemed to appreciate or have much desire to do anything about. Worse, whenever state medical boards actually did something about it, it became obvious that quacks had considerable political pull in some states. The example that I like to cite the most often is that of Dr. Rashid Buttar, whom I mentioned earlier. Buttar led a successful effort by the North Carolina Integrative Medical Society to get legislators to change state law to make it friendlier to practitioners of alternative medicine.

Then the pandemic hit, and finally the severity of the problem of doctors using their professional status to spread misinformation is being appreciated, perhaps for the first time. Unfortunately, we as a profession have a lot of members who either can’t or don’t want to see it as a problem. I suspect that the reason now is similar to the reasons then, involving our dislike of “being told what to do” and an attitude that any of us could fall victim to a bogus complaint to a state medical board. (Ironically, I myself have experienced exactly that, when several years ago a patient of Stanislaw Burzynski reported me to my state medical board for my blog posts about her case.) I get it. I also get that a lot of my colleagues and I have to make medical decisions based on less than ideal evidence bases all the time (the “art” of medicine). Unfortunately, too many of us extrapolate that to justify what quacks do.

That needs to change, and we need to work to clean up our own profession. Before the pandemic, I wouldn’t have cared so much where we started, with quacks like Stanislaw Burzynski or with antivaxxers like Paul Thomas. Given that we are still in the middle of a pandemic that’s killed northward of 800K in just the US alone, starting with doctors promoting COVID-19 misinformation makes a lot of sense. As imperfect as it is and even if it doesn’t go far enough for my tastes, NLFD is as good a strategy to start with as any. Again, this is professional quality control, not “cancel culture”, and, even if it were, not all “cancel culture” is a bad thing.