Nov 14 2008
This is the final entry in the current series having to do with state regulation of physicians.† It is the final one merely because I’m tired of the topic, for now. There is plenty more to write about, including an event that occurred only yesterday right here at my own hospital. I’ll give a preview of that at the end of this post, but first we’ll look at another recent event.
Arizona’s citizens, more than most, can expect to be bamboozled by pseudomedicine. We’ve seen that the Arizona Board of Homeopathic Medical Examiners has, for years, provided a regulatory safe haven for quacks with MD and DO degrees. Although I haven’t previously mentioned it in this series, which is about quack medical doctors, Arizona is also a haven for another group of quacks: “naturopathic doctors.” Like its homeopathy board, Arizona’s Naturopathic Physicians Board of Medical Examiners has been less than committed to protecting the public from its licensees. In each board’s case, the state Office of the Auditor General has suggested numerous fixes, but there has been little indication of improvements.
Nor would improvements be expected: in the words of Edzard Ernst,
Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.
Arizona is also the home of one of the first academic “integrative medicine” programs, begun by Andrew Weil at the University of Arizona. We have previously seen examples of misleading language emanating from that program. We’ve also seen the program’s inordinate effect on the Federation of State Medical Boards (FSMB). We’ve seen examples of the writings of Kenneth Pelletier, one of the U of Arizona program’s consultants to the FSMB. A recent disciplinary case in Arizona illustrates the potential danger of a state medical board seeking consultation from another “integrative medicine expert” from that program.
The Arizona Medical Board had first disciplined psychiatrist John Dommisse, a practitioner of “nutritional and metabolic telemedicine,” in 2003. As has been the case for other quacks, the Board’s leniency at that time merely postponed the inevitable: new findings resulted in more investigations. Finally, in August 2008, the Board revoked Dommisse’s license to practice “allopathic” medicine in Arizona. [The misnomer itself is an indictment of how political interests get translated into regulatory schemes.]
Dommisse’s practices had included frequent “diagnoses” and reckless treatments of ‘thyoiditis,’ ‘candida overgrowth,’ ‘immune deficiency,’ ‘multiple chemical sensitivity,’ ‘vitamin deficiencies,’ ‘hormonal deficiencies,’ ‘amino acid deficiencies,’ ‘chronic mycoplasma pneumonitis,’ ‘macrocytosis,’ ‘metal toxicity,’ and more. He did not perform physical examinations, nor did he justify such diagnoses on the basis of accepted criteria; rather, he relied on dubious blood tests. An excerpt from the Board’s Findings of Fact in the most recent action (linked above, beginning on p. 10) is illustrative:
In January, 2005, Dr. Scheerer [the Board's consultant] reviewed 10 files from Dr. Dommisse’s office, which had been selected at random. The files were similar in many respects, including the following:
a. an intake sheet prior to the first appointment, consisting of the patient’s main complaints, age medical insurance, willingness to have one-third pint of blood drawn for tests, and notification that Tiburon Diagnostic Laboratory was Dr. Dommisse’s laboratory of choice and that the patient could save significant expense by paying up front privately for tests;
b. a private contract for patients on Medicare, since Dr. Dommisse does not take assignment;
c. a disclaimer form since Dr. Dommisse does not do routine physical examination, only focused examination when indicated…
d. notes in the margin of the intake sheet and a one-to-two-page report of presenting problem, medications, food and drug history, and systemic review; and
e. provisional diagnoses and recommendations with the first recommendation almost routinely being “Several vitamin, mineral, special thyroid and other blood tests to find the causes or other aggravating factors in these conditions” (this recommendation is referred to below as “the standard recommendation”).
Dr. Dommisse then orders a large number of laboratory studies that almost routinely include CBC, chemistry panel, lipid panel, thyroid panel, including anti-TPO autoantibodies, vitamin B-12, vitamin D, vitamin E, IGF-1 (growth hormone), amino acid profile, basic food panel, numerous metals, candida antibodies, Mycoplasma antibodies, and NK ["natural killer cell"] function. Other studies are also frequently ordered including testosterone, estradiol, progesterone, osteocalcin, and free insulin levels.
Dr. Domisse did not record a progress-follow-up note on any of the ten charts inspected.
Dr. Dommisse did not record a physicial examination, even focused, on any of the ten charts at any point in his care of the patient.
… Dr. Dommisse’s charts were exceedingly difficult to follow. The SOAP format, which stands for the patient’s Subjective complaint, the physician’s Objective findings, the physician’s Assessment or impressions or conclusion, and a Plan of treatment, is standard for every allopathic physician’s records of every office visit. Dr. Dommisse’s charts do not include any of the SOAP elements. A subsequent physician would have to spend hours analyzing Dr. Dommisse’s charts to have any idea what he did to treat the patient’s complaints with what outcome. The results of treatment were especially hard to ascertain, since Dr. Dommisse did not perform physical examinations. The laboratory results were in no order. Dr. Dommisse made comments on lab sheets that were hard to follow. Dr. Scheerer could not determine Dr. Dommisse’s thoughts on patient care from visit to visit.
Among the Board’s findings were that Dommisse had unnecessarily prescribed estrogen replacement for a 72 yo woman, and then failed to respond appropriately when she reported to him, repeatedly over several years, that she had persistent vaginal bleeding; that he had diagnosed “autoimmune thyroiditis” in almost every patient whose records were examined, without adequate supporting evidence; that he had “alter[ed] laboratory reference ranges to interpret normal laboratory results as abnormal”; that several patients developed abnormal heart rhythms or other manifestations of hyperthyroidism after Dommisse had inappropriately prescribed thyroid replacement; that after diagnosing ”aluminum toxicity” in a 29 yo woman, he “performed chelation therapy without documenting informed consent”; “that, when a patient of Dr. Dommisse decides for whatever reason to seek a second opinion, if the subsequent physician does not understand or agree with Dr. Dommisse’s care of the patient, his practice is to bully the patient”; and that he used “improper Current Procedural Terminology (‘CPT’) coding to bill at a higher rate.”
Among Dr. Dommisse’s rebuttals were these:
…he tells patients that he relies on others to perform physical examinations. He did not show the report of any physical examination by another health care provider…
Dr. Dommisse testified that psychiatrists cannot perform detailed physical examinations. They examine patients by observing them during conversations. He performed his last physical examination approximately 41 years ago.
Dr. Dommisse had admitted into evidence a paper he authored entitled “Hypothyroidism: Sensitive Diagnosis and Optimal Treatment of All Types and Grades—A Comprehensive Hypothesis.”
Dr. Dommisse testified that the risks of excess estrogen replacement are “ridiculous.” The dangers of thyroid hormone over-replacement have been “blown out of proportion.”
Dr. Dommisse testified that all the substances that he prescribes are “natural” and therefore “harmless.” He placed [a patient on] hydrocortisone, which is identical to the naturally occurring substance. Hydrocortisone cannot be patented because it is identical to the substance that occurs naturally in the body. In contrast, internists prescribe prednisone, which increases drug companies’ profits and may cause harm because it is not natural.
His diagnosis of mycoplasma pneumonitis was of a condition that might, if left untreated, progress to “walking pneumonia.”
Dr. Dommisse testified that nutritional physicians’ patients do not get tardive dyskinesia. [a devastating, irreversible complication of the long-term use of anti-psychotic medications such as Seroquel, which Dommisse commonly prescribed for anxiety]
Dr. Dommisse offered into evidence 21 letters from physicians in support of him, which generally attest to the success of patients that they refer to him rather than specific practices. [He] also offered into evidence letters from 119 patients about their success under his treatment.
Of the Board’s 5-6 consultants for the case, all but one agreed that Dr. Dommisse’s practices and documentation were substandard and dangerous. The exception was Randy Horwitz, MD, PhD, the medical director of the U of Arizona Center for Integrative Medicine. Discussion of his report begins on p. 40 of the Board’s findings. He seems to have bent over backward to judge Dommisse’s practices not only acceptable, but exemplary:
With respect to the Board’s charge that Dr. Dommisse had possibly committed unprofessional conduct by altering the ranges of values that the laboratory had designated as normal, Dr. Horwitz’ initial report rendered the following opinion:
In this most serious charge, I believe that the accusation was ill-stated, vague, and largely unfounded. In examining the laboratory reports in this case, it appears that Dr. Dommisse re-defined the Quest Laboratory reference range to suit his view of where the patients value should optimally lie. This was neither a malicious nor illegal act, in that the lab results form was clearly revised by Dr. Dommisse; indeed, the original reference range is still readable.
Er, wouldn’t that have been for Dr. Dommisse’s eyes only? That is, if the Board hadn’t intervened? Nope, says Horwitz:
It appears to me that Dr. Dommisse actually took the time to discuss each lab value with the patient—and likely modified or discussed his opinion of the ranges in the presence of the patient.
How could Horwitz possibly have known that?
He has circled the patient’s lab value, then noted his view of the optimal values (versus the reference range reported by Quest). Not only is it within his rights as a physician to do such, it should be encouraged. As a consultant, I am often called upon to explain the meaning of the patient’s lab values, since they are not routinely discussed in detail with the patient by the PCP. It is a refreshing change to see this level of detail in discussing lab values.
Ah, a master of self-flattery and strawman erection. No surprise, then, that bait-and-switch comes next:
I might point out that a reference range is not always equivalent to an “optimal value” for a particular lab value. In fact, the “altering” of a reference range is commonly done in Internal Medicine…
Regarding Dr. Dommisse’s charts being “exceedingly difficult to follow,” Dr. Horwitz again demurred:
I saw no evidence to support these claims. The records were rather complete, and I believe that Dr. Dommisse believes everything he has written. Many conventional physicians disagree with the manner of his practice (Nutritional Medicine), but if we restrict our focus solely to the issue of these allegations, it becomes easier to reach conclusions.
There seems to be a special language of record-keeping that only “integrative physicians” can understand:
Dr. Dommisse argued that [none of the other consultants] were his peers because they did not practice nutritional medicine. Only Dr. Horwitz was his peer, and Dr. Horwitz found no fault with his record-keeping or diagnostic practices.
Dr. Dommisse testified that Nutritional physicians do not follow the SOAP format in their record-keeping. Other nutritional or complementary physicians, such as Dr. Horwitz, could understand his charts.
Dr. Dommisse testified that his patients had told him that they did not want to pay for the additional expense of having him prepare office notes in the SOAP format for each office visit. They preferred to have him spend his time focusing on treatment and care.
I’m tempted to let that passage stand without comment, knowing that every practicing physician reading it is likely to be overcome with cynical laughter. For non-physicians, however, it might require a bit of explanation. First, real practicing physicians couldn’t imagine being paid more for writing a competent note. Anything less would be unthinkable, even if it means spending a couple of extra hours per day, without extra pay, to do it. Next, the SOAP format was devised precisely to make such documentation as efficient as possible. It is quick, to the point, and easy to follow. Finally, it is unlikely that many patients would volunteer opinions about SOAP notes. Unless, that is, those patients had been urged to do so by a doctor whose practices are not reimbursed by health insurers, and who thus charges patients directly. A doctor not like any that most of us know (other than cosmetic surgeons), but a doctor like Dommisse.
Back to Horwitz: to give him his due, he reviewed only one of Dommisse’s charts, and it’s possible that this chart was an exception to the norm. Horwitz found fault with Dommisse’s initial dosing of thyroid replacement for that patient (p. 43), but that was his only real criticism, in the midst of what otherwise was a generous exoneration.
Horwitz managed to convince the board that there is “a good-faith controversy within the allopathic medical community regarding optimal ranges [of serum vit B12 and TSH levels] for specific patients” and “regarding the appropriate diagnostic test for hypothyroidism.” (paragraph 3, pp. 54-55). Fortunately, that wasn’t enough to get Dommisse off the hook in this case. It certainly demonstrates the danger of “quackademics” judging quacks, however. It is easy to imagine that if the only consultants had been “integrative physicians,” Dommisse would still be ministering to an unwary public. Such a state of affairs already exists in some states, and there is pressure to expand it. New York is an example.
A New York State of Mind
A few months ago we saw that the New York State Board for Professional Medical Conduct had failed to revoke the license of Nicholas Gonzalez in the 1990s, although it had more than ample grounds for doing so. According to Victor Herbert, the board was swayed by the testimony of two academics. Neither was an expert in cancer, but each argued that Gonzalez had a promising cancer therapy. I suggested at the end of that long series that perhaps the reason we’re not likely to see a report of the NIH-sponsored trial of the “Gonzalez regimen” for cancer of the pancreas is that it would demonstrate that the two academics had been wrong, thus spreading much embarrassment: to the New York Board for not having revoked Gonzalez’s license, and to the NIH, Columbia University, and the pertinent IRB for having entrusted Gonzalez with the care of human subjects—which, in at least one case, proved to be more torture than care.
Although that might not be the reason for the data embargo, the fact remains that a disconfirming outcome would remove the only historical basis for allowing Gonzalez to keep his medical license, and would be embarrassing to the institutions cited above. Even if such a trial outcome becomes public, however, it will probably not result in Gonzalez’s license being revoked. Too much time has passed, and the mood of society has changed—for the worse, regarding purveyors of implausible medical treatments. Gonzalez will probably have to injure a few more patients before the New York Board puts him back in its sights.
At about the time that Gonzalez was being investigated by the New York board, the state was beginning to succumb to the “quacks should be judged only by other quacks” argument, culminating in the Alternative Medical Practice Act of 1994. Here is a description of the Act according to the Foundation for the Advancement of Innovative Medicine (FAIM), a PPO founded by the late “diet doctor” Robert Atkins:
The New York act, Chapter 558 of 1994, amended one section of the education law and two sections of the public health law:
Education Law, Section 6527(4).
(4) This article [Article 131.] shall not be construed to affect or prevent the following:
(e) The physician’s use of whatever medical care, conventional or non-conventional, which effectively treats human disease, pain, injury, deformity, or physical condition.
Public Health Law, Section 230, Subdivision 1.
A state board for professional medical conduct is hereby created. . . not fewer than 2 of whom shall be physicians who dedicate a significant portion of their practice to the use of non-conventional medical treatments who may be nominated by New York state medical associations dedicated to the advancement of such medical treatments. . .
Public Health Law. Section 230, Subdivision 10(a) Investigation. (ii) If the investigation of cases referred to an investigation committee involves issues of clinical practice, medical experts shall be consulted. Experts may be made available by the state medical society of the state of New York, county medical societies and specialty societies, and by New York state medical associations dedicated to the advancement of non-conventional medical treatments.
[Enacted July 26, 1994]
(Note: New York utilizes legislative intent to clarify terms of laws, in this case, effectively treats is clarified to mean “has been shown to be effective but has not yet gained general acceptance in the United States.”)
Nice weasel-wording. New York has been true to that law: one of the self-described state board members, since 1995, is the Executive Director of the Beth Israel Medical Center’s Continuum for Health and Healing (CCHH), Woodson Merrell. Dr. Merrell seems to believe in every implausible medical claim, no matter how ridiculous. Thus it is unnerving to read that:
At CCHH Dr. Merrell supervises an extensive array of consumer and educational programs. These include training for medical, chiropractic and acupuncture students, as well as for residents and fellowships in integrative medicine. He is a member of the working group on curricular reform for integrative medicine at Albert Einstein College of Medicine. He is committed to public policy and practice standards in integrative medicine, having testified on integrative medicine to both Houses of Congress, as well as New York City and State agencies. He has served as Chairman of New York State’s Board of Acupuncture, and since 1995 has been a Board Member of New York State’s Office of Professional Medical Conduct. Dr. Merrell is on the Steering and Policy Committees of the national Consortium of Academic Health Centers for Integrative Medicine. This is an organization comprising 25% of the nation’s medical schools (including Harvard, Duke, Penn, Columbia, UCLA, Michigan, Einstein, Arizona, UCSF, Maryland, and Georgetown), pledged to transform medical education and physician training with integrative medicine.
Dr. Merrell has lectured extensively to both consumer and professional groups on integrative medicine and the nature of healing and wellness. He has been a consultant to many hospitals, medical centers and medical schools to help increase their integrative approach to healthcare. He is a frequent guest for all major media both regionally and nationally, including CBS Morning Show, CNN, MSNBC, WABC, the View, NPR, WBAI, Sirius, Time, Forbes, Barrons, Leaders, W, Elle, Self, NY Times, Wall Street Journal, NY Post, and the Daily News. Dr Merrell passionately believes that integrative medicine is the future of medicine, that there is significant evidence-basis for its use right now, and that utilizing this approach while empowering the patient and providing compassionate, relationship-centered integrative care is critical for transforming the nation’s ailing healthcare system.
Whether or not Merrell or the Alternative Medical Practice Act are responsible, New York seems to be a good home for quackery. While investigating the NIH chelation trial (TACT), I became aware of several New York physicians (TACT Co-Investigators) who practice “Questionable and Deceptive Health Care Practices” in the extreme: their websites are here, here, here, here, and here. With one exception, they seem to have escaped scrutiny by the state board. The exception is Michael Schachter, a psychiatrist who for years has openly admitted to administering Laetrile (“amygdalin“) and numerous other quack treatments. In the 1970s, Schachter was investigated by what was then called the State Board for Professional Misconduct. The Board had reason to believe that Schachter had treated cancer patients “with the drugs Laetrile or MA-7.”
I haven’t been able to discover the eventual disposition of that case, but it seems to have bothered Schachter enough to have turned him into an activist for “health freedom.” Schachter is another former president of FAIM, and seems to have been a key player in its successful campaign to persuade the New York State legislature to enact the Alternative Medical Practice Act of 1994. According to FAIM, however, the New York Office of Professional Medical Conduct is still harrassing “good” doctors, including several who are pushing “chronic Lyme disease.” Maybe there is some hope.
The Buck Stops…Nowhere
Here is the tidbit I promised you at the beginning. A couple of days ago I received the following email pitch from a nearby group medical practice, about one of its new doctors (“redacted” by me):
We are pleased to announce that _________, M.D., has joined us as a primary care physician in our _______ Center.
Dr. ________ comes to us from New York where she founded and ran an Internal and Integrative Medicine Practice, implementing a variety of alternative treatments, including life style modifications, nutritional and detoxification protocols, Intravenous Vitamin treatments, Oral and Intravenous Chelation methods, bioidentical hormone replacement, chronic Lyme treatments, and many others.
She completed American Academy of Environmental Medicine courses in allergy treatments and gave multiple lectures in the community to educate the population and promote the practice. Dr. _______ studied management of chronic Lyme treatment with Dr. Richard Horowitz through ILADS sponsored preceptorship and used alternative methods of testing utilizing various laboratories, including Doctor’s Data, Genova Diagnostics, Metametrix, Neuroscience, and Igenix.
Dr. __________ received her undergraduate degree from Brandeis University, her medical degree from St. George’s University and is board certified in Internal Medicine. She is the co-author of several peer reviewed journal articles.
Dr. ___________ says, ”I practice medicine of the future, which keeps my patients healthy instead of labeling them with diagnoses and providing pharmaceutical band-aids. I spend as much time as it takes to look into the root cause and dynamics of potential diseases. Integrative nutrition and healthy lifestyle completes this rejuvenation approach.”
Dr. __________ has already been made a member of the staff of “my” hospital. It seems that the materials she provided to the credentials committee didn’t include the information quoted above. Now that pertinent members of the medical staff are aware of that information, it is still not clear that anything will change, because she won’t be doing that stuff in the hospital—only in the office. I guess that’s not “our” concern.
† The State Regulation Series:
- Pitfalls in Regulating Physicians. Part 1
- Pitfalls in Regulating Physicians. Part 2: The Games Scoundrels Play
- The Pseudomedical Pseudoprofessional Organization (PPO*)
- A New Twist for Autism: A Bogus “Biomedical” Board
- How State Medical Boards Shoot Themselves (and You) in the Foot
- “Integrative Medicine Experts”: Another Barrier to Effective Discipline
- Bogus Diagnostic Tests
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