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Note: This post is being republished from MedPage Today where it was originally titled "Rogue Doctors and Boundaries: How Far Past the Mainstream Should Healthcare Professionals be Permitted to Go?"
Physicians tend to value their independence when it comes to how they are allowed to practice and what they are allowed to think. After all, medical science often fails to deliver clear-cut answers even for relatively straightforward questions. Physicians also (as of now) are still human beings subject to the same biases and aspirations as everyone else. Put all of that together, and we are left with a fairly remarkable amount of latitude within which medical professionals operate. Sure, there are boundaries that can’t be crossed without penalty for things like mistreating patients or filling out false billing claims, but when it comes to the medical advice that healthcare professionals can give, doctors are given an incredibly wide berth.
In return, patients and other individuals who consume these opinions tend to trust that science and prevailing standards of practice play a pretty major role in a doctor’s viewpoint, but what if that assumption is wrong?
“(The public) thinks that once you have the degree, you are qualified to pontificate about anything,” declares Dr. Joe Schwarcz, Director of the McGill Office for Science and Society in Montreal, Quebec. This group, whose motto is “separating sense from nonsense” represents a growing number of individuals and organization that are becoming increasingly concerned with the vast amount of misinformation that is being disseminated by various types of healthcare professionals, often to promote miracle cures for everything from autism to obesity. “The public,” Dr. Schwarcz says, “is very easily seduced.”
Their main weapon to fight bad information: good information, which is posted online, sent out into social media, and delivered live at lectures and conferences. But is this enough? Worry about scientifically unsupported practices and recommendations from other types of medical providers, such as chiropractors and naturopaths, has led some to question the need for an even stronger approach. Timothy Caulfield, an outspoken critic of pseudoscience and the Canada research chair in health law and policy at the University of Alberta, recently called for the creation of an independent body tasked with regulating the claims of alternative health professionals after complaints were filed about homeopathic assertions of a total cure of autism. If commercial products can’t make false claims about their health benefits, after all, why should the people entrusted with the health of others be allowed to make those same proclamations?
Alarms have also been raised among more traditionally trained doctors who receive M.D. and D.O. degrees. Recall not too long ago an online op-ed column in January 2017 written by Dr. Daniel Neides, the former Director of the Wellness Institute at the prestigious Cleveland Clinic, in which he supported the idea that vaccines cause autism, an allegation that has been systematically debunked from multiple independent studies. The public outcry for this article was swift and harsh, pushing The Cleveland Clinic to relieve Dr. Neides of his position. There was also the now famous congressional hearing with celebrity physician Mehmet Oz (Dr. Oz) in which he was asked to defend claims he made on his show about the “miracle” diet pills he was promoting in the absence of scientific evidence.
Some of these cases can be easily connected to potential conflicts of interest with pharmaceutical companies, book deals, and supplemental nutritional products. But many, if not most, of the healthcare professionals out there espousing more “fringe” positions do so out of personal conviction and their understanding of the truth. Making matters more complicated is the fact that what constitutes a fringe or scientifically ungrounded opinion is very much a continuum. Consider, for example, the following positions a doctor might take, all of which would be considered outside of standard practice and contrary to the preponderance of scientific evidence.
· A pediatrician who advocates co-sleeping for young infants despite the published links with sudden infant death syndrome (SIDS)
· An internist who refuses to prescribe antidepressants because he doesn’t “believe” in them
· A family medicine physician who has her patients do a slower vaccine schedule under the belief that the recommended schedule may increase the risk of autism
· A psychiatrist who recommends hyperbaric oxygen therapy for autism and Alzheimer’s disease.
All of these opinions run contrary to official positions from their corresponding specialty organizations, and all three could certainly result in patients being put at significant risk as a result. But do these views go far enough to trigger a response, and who gets to decide?
Critics of pseudoscience concede that the line between being unconventional and being a “quack” can be hard to draw at times, but that doesn’t mean there isn’t some low hanging fruit out there. “Antivaccine views, promoting outright quackery like homeopathy, persuading patients to eschew science-based treatment,” are some examples of views and behavior that go too far, according to surgeon and researcher Dr. David Gorski who, under the nom de blog Orac, maintains the popular blog Respectful Insolence to refute “pseudoscience claims made by quacks, cranks, and anti-vaxxers.”
As for who should do the monitoring of extreme healthcare professionals, there are, in fact, quite a few organizations that at least in theory would be in a position to evaluate and, if deemed appropriate, take some kind of action against a doctor who operates too far outside acceptable parameters. These would include state medical license boards, university departments, board certification bodies, and professional organizations such as the American Medical Association or American Academy of Pediatrics that often explicitly define the standard of care for their members. But as can happen when there exist many potential groups that could be involved in performing a particular action, what frequently occurs is that none end up taking ownership and stepping up to the plate. While all of these groups might be forced to look into a specific complaint that is filed, there surprisingly seems little appetite to tackle this problem on a wider scale. The current president of the American Academy of Pediatrics (AAP), Dr. Colleen Kraft, declined to offer any opinion about particular viewpoints or practices that the AAP would consider too extreme, or what action they would take, if any, if a pediatrician was recommending them. The American Medical Association and American Academy of Family Physicians didn’t respond to my questions about this at all. Overall, these groups seem much more comfortable advocating for issues that unite their entire membership than trying to police individual members.
Arguably, it would be the job of a state’s medical board to decide whether or not a particular doctor’s views were too far outside the mainstream, and what should be done about it. As such, I reached out to my own state of Vermont’s Board of Medical Practice and their Executive Director, Dr. David Herlihy, who did agree that a Board of Medical Practice could get involved if there were sufficient evidence that a physician’s practice rose to the level of unprofessional conduct or was a sign that a particular doctor was significantly impaired. In discussing the example regarding vaccines, Dr. Herlihy responded that a violation of state laws could occur, “If the parents of a child provided statements indicating that the licensee had been asked about vaccinations and provided materially false answers, or if the views held by the licensee were reflected in the provision of medical services that fails to meet the essential standards of acceptable and prevailing practice (failure to meet the standard of care)…”
Even if an organization or regulatory body shows reluctance to take more punitive action, another potential intervention would be to send some kind of official “Hey Dr. xxxxx, cut this crap out!” message that would alert the healthcare professional, and maybe that person’s patients, that a particular opinion or practice is veering away from best practice guidelines.
But many, if not most, physicians would find such a message coming from a large and impersonal regulatory body to be useless and insulting. Indeed, letters like this already come to doctors' mailboxes from insurance companies “alerting” them that a particular patient is taking a particular medication that may be problematic or lacks substantive evidence for its efficacy. The response is usually a shrug. After all, doctors spend a great deal of time and money learning to become experts in their fields through practice and the interpretation of medical research that can often be inconclusive, inconsistent, and sometimes outright contradictory. As a result, they tend not to put much stock in any kind of bureaucratic organization, whether it be an insurance company, government entity, or professional group, giving them clinical advice, especially for an individual patient. Indeed, many health care professionals are already quite aware that their opinion on a particular medical topic deviates from the status quo and wear that badge proudly and openly on their social media sleeve.
Which is all why people like Dr. Schwarcz aren’t looking to enact new legislation or create big brother agencies that can crack down on health care professionals who cross some hard to define boundary between legitimate differences of opinion and quackery. To him, you have to fight fire with fire. “All we can do is write about and alert as many people as possible,” he contends.
In the end, we are left with the conclusion that while mainstream medical organizations are getting better and better at reaching the public to deliver good evidence-based health information, they are much more skittish about refuting pseudoscience and downright timid when it comes to calling out particular individuals, some of whom may be members of their own organization. Like it or not, the burden may continue to fall on individual watchdog organizations and public complaints to expose health-related opinions and recommendations that may sound technical and valid but are devoid of any actual scientific support.
