State medical boards have always been toothless

You really think it’s all new.
You really think about it too
The old man scoffed as he spoke to me,
I’ll tell you a thing or two.

The Clash, Something About England

[Orac note: Orac had a big grant deadline last week, explaining the lack of new material. This week, Orac is recharging his Tarial cells (i.e., is on vacation). There will likely be a new post or two, because blogging is his hobby, but no guarantees. Regular activity should resume in full next week.]

The Washington Post recently published an investigation that, unfortunately, jibes with much of what I have been writing about state medical boards for over 15 years. Reported by Lena Sun, Lauren Weber, and Hayden Godfrey and entitled Doctors who put lives at risk with covid misinformation rarely punished, the story is a great overview of the shortcomings of state medical boards that have been laid bare by the COVID-19 pandemic. However, as I will discuss, the problems with the regulation of physician practice by state medical boards go back long before the pandemic, which was a stress test on state medical boards that, for the most part, they have failed miserably. My first reaction to the story was a bit cynical, too, specifically some amazement that as many physicians as were described in the story had actually faced repercussions for their spreading dangerous misinformation about COVID-19 and even practicing outright quackery claiming to treat or prevent it. That’s just me, though. (Or maybe it isn’t.)

For the story, the three Post reporters did an analysis of disciplinary records of state medical boards for all 50 states, and in this case they don’t bury the lede:

A Wisconsin doctor in 2021 prescribed ivermectin, typically used to treat parasitic infections, to two covid-19 patients who later died of the disease. He was fined less than $4,000 — and was free to continue practicing.

A Massachusetts doctor has continued practicing without restriction despite being under investigation for more than a year over allegations of “disseminating misinformation” and prescribing unapproved covid treatments, including ivermectin, to a patient who died in 2022, according to medical board records.

And in Idaho, a pathologist who falsely promoted the effectiveness of ivermectin over coronavirus vaccines on social media has not been disciplined despite complaints from fellow physicians that his “dangerous and troubling” statements and actions “significantly threatened the public health.”

Across the country, doctors who jeopardized patients’ lives by pushing medical misinformation during the pandemic and its aftermath have faced few repercussions, according to a Washington Post analysis of disciplinary records from medical boards in all 50 states.

To say that this finding was…unsurprising…to me is an understatement. I’ve been writing about attempts to discipline dangerous physicians spreading COVID-19 misinformation and using quackery to treat the disease (the two very frequently go together hand-in-hand), and for every positive development that brings a ray of hope that state medical boards are beginning to understand I seem to find a lot more signs, like the Post story I’ll discuss (which features some doctors who have shown up on this blog before), for despair.

State medical boards and the failure to discipline physicians

State medical boards have long been a topic here and at one of my favorite blogs, for example, when Dr. Kimball Atwood devoted a series of posts about the pitfalls and failings in how state medical boards had been growing more and more open to medical “pseudospecialties” or “pseudodisciplines,” as we like to call them. He began by discussing how, as a result of advocacy by groups representing naturopaths, several states had been becoming more accepting of naturopathy, to the point of considering legislation that would legalize and regulate some of its quack treatments as though they were legitimate—or even the specialty itself—in, for example, Minnesota, Colorado, Massachusetts, and elsewhere. Unfortunately, the problem went beyond just the political question of deciding whether to regulate naturopathy as though it were a legitimate medical specialty, and to demonstrate this Dr. Kimball followed up with discussions of state medical boards investigating actual MD/DO licensed physicians who used actual quackery (e.g., intravenous hydrogen peroxide and chelation therapy for anything other than the existing very narrow conditions for which it is indicated), concluding with a discussion of how academic practitioners of what was then called “complementary and alternative medicine” (CAM, now more frequently called “integrative medicine” or “integrative health”) had been pressuring state medical boards to accept outright quackery as being legitimate medical treatments. Jan Bellamy also used to write frequently about state medical boards and their shortcomings when they were faced with disciplining physicians, as well as about efforts by advocates for medical pseudospecialties like naturopathy to persuade state legislatures to pass laws legitimizing their quackery and even turning them into legally recognized and regulated medical specialties. She even invented an apt term, “legislative alchemy,” to describe the efforts of advocates to persuade legislators to turn the lead of quackery (e.g., naturopathy and chiropractic) into the gold of a recognized medical specialty.

I myself not infrequently wrote about the failings of state medical boards with respect to physicians practicing actual quackery. It began with the attempt by the North Carolina Board of Medical Examiners to discipline Dr. Rashid Buttar for his use of chelation therapy to treat autism and cancer. During the proceedings, Dr. Buttar famously (to us, anyway) called the Board a “rabid dog.” Ultimately, however, instead of permanently revoking Dr. Buttar’s medical license, the Board gave him a slap on the wrist, telling him that he could no longer treat children or cancer patients, rather than, as I put it at the time, “having his medical license stripped from him, cut up in front of his face, and then the fragments ritually burned,” which is the penalty that I thought he so richly deserved. What ultimately happened, despite the minor restrictions placed on Dr. Buttar’s practice was quite different.

Dr. Buttar, it turned out, was a significant “pioneer” of what became an all-too-common and distressing tactic among quacks since COVID-19: Attacking state medical boards and any other medical authority trying to rein in quacks and misinformation. His was the template that COVID-19 disinformation spreading doctors followed. Most people combatting disinformation now don’t appreciate just how influential Dr. Buttar was in terms of taking the war straight to state medical boards. Indeed, he and his allies eventually persuaded the state legislature to alter North Carolina state law to make it more quack-friendly by mobilizing public support to neuter the North Carolina Medical Board and prevent it from disciplining doctors who practice quackery associated with “integrative medicine.” Specifically, the 2008 law, passed due to the advocacy of the North Carolina Integrative Medical Society and Dr. Buttar, prevents the medical board from disciplining a physician for using “non-traditional” or “experimental treatments” unless it can prove they are ineffective or more harmful that prevailing treatments. In the end, Dr. Buttar basically won his battle with the North Carolina State Medical Board after losing what was in retrospect a relatively minor battle.

Another case in particular led to my writing about the failure of state medical boards more than any other, that of Dr. Stanislaw Burzynski, the Polish expat physician who has been making extravagant claims for his unproven treatment for cancer, something he calls antineoplastons, since the late 1970s and, at 80 years of age, is still practicing in Houston, TX. Indeed, after the multiple hagiographies of a “brave maverick doctor” who’s “curing cancer” despite the resistance of the medical establishment, he still appears to be thriving. I’ve even seen the 2016 hagiography, Burzynski: The Cancer Cure Cover-Up, resurfacing on many of the same sites promoting COVID-19 misinformation, leading me to wonder if Burzynski has decided that antineoplastons are good for COVID-19 too. The main depressing point of my bringing up Burzynski is that, despite multiple attempts by the Texas Medical Board to discipline him for using unproven (and ineffective) treatments while charging patients huge sums of money, the last failed attempt in 2017, and attempts by the FDA to stop him, Dr. Burzynski is still in business. I also like to note when I discuss Dr. Burzynski how he pioneered many of the same misinformation techniques used today by doctors promoting COVID-19 misinformation, including cultivating relationships with sympathetic politicians and, above all, wielding believing patients as sympathetic shields against attempts to discipline him.

I also used to comment about how infrequent it was for outright antivax quacks who openly discouraged parents from vaccinating their children to face discipline prepandemic, asking what we should do about antivax physicians. Indeed, when such physicians did actually face discipline from their state medical boards, it was frequently based on other problems, such as how inadequate documentation brought down Dr. Bob Sears and use of homeopathy brought down Dr. Paul Thomas. Much of the time, it’s other offenses, not the quackery and antivax misinformation for which physicians were best known, that finally pushed state medical boards to act.

Unfortunately, a lot of upstanding physicians practicing science-based medicine are unduly disturbed by even the suggestion that state medical boards should discipline a physician for spreading misinformation about COVID-19. As much as I argue that it is not “cancel culture” but rather quality control to do so, political messaging has been successful in persuading all too many physicians to view attempts by state medical boards to discipline COVID-19 misinformation spreaders as potential threats to them.

How effective have state medical boards been? Not very

After the lede, the Post notes:

State medical boards charged with protecting the American public often failed to stop doctors who went against medical consensus and prescribed unapproved treatments for covid or misled patients about vaccines and masks, the Post investigation found.

At least 20 doctors nationally were penalized for complaints related to covid misinformation between January 2020 and June 2023, according to board documents, which The Post obtained by filing requests with state medical boards and reviewing public records. Five of those doctors lost their medical licenses — one had his revoked, while four surrendered theirs. Discipline is typically connected to patient care, not just what doctors say.

Again, I can’t help but expressing amazement that it was 20 physicians who were disciplined and five who actually lost their licenses to practice medicine. I would have guessed smaller numbers, much smaller. I will note that the Post nails the reasons why state medical boards often fail to act:

But they [state medical boards] are barely able to keep up with the more mundane task of issuing licenses, doctors say, let alone monitor social media, where many of the false claims proliferate. Critics say the system is not up to the task of overseeing the medical industry, and was particularly unable amid the explosion of misinformation that accompanied the pandemic.

“We allow the profession to police themselves. And when they fail to do that, even in the most egregious cases, what they are abetting is the erosion of trust and respect for doctors,” said Wendy Parmet, director of Northeastern University’s Center for Health Policy and Law, who has written about the harms of covid misinformation.

And:

Doctors don’t normally face discipline for promoting treatments that go against medical consensus because state boards are loath to tread on physicians’ medical judgment and First Amendment rights, according to doctors and members of medical boards. Physicians commonly prescribe drugs for conditions other than those they were approved for, a practice known as “off-label” use that boards do not want to curtail.

“State boards can only do limited things,” said Humayun Chaudhry, president of the Federation of State Medical Boards, a nonprofit that represents the licensing agencies. “The most common refrain I hear from state licensing boards is they would like to have more resources — meaning more individuals who can investigate complaints, more attorneys, more people who can process these complaints sooner — to do their job better.”

As I’ve said many times over the years, state medical boards are often underfunded and understaffed to the point where they can barely deal with obvious cases requiring urgent intervention, such as cases of physicians impaired by alcohol or other substance abuse disorders, grifting physicians running prescription mills, or physicians engaging in outright fraud. Cases of physicians practicing quackery—or, in the case of ivermectin and hydroxychloroquine after 2020, when studies had definitively shown they don’t work—as “off-label prescribing” are more difficult and resource-intensive to pursue, if only because many of these quacks have significant resources to afford top flight law firms to represent them in front of the board, indeed far more resources than the board itself often has. Then, when it comes to misinformation, there’s always the issue of the First Amendment and the reluctance to penalize a physician for what, misinformation spreaders will claim, is Constitutionally protected speech. On the other hand, speech frequently goes hand-in-hand with quackery. Misinformation-spreading physicians often base their treatment of COVID-19 patients on the misinformation, sometimes with serious grifting, as when America’s Frontline Doctors were busted for running an ivermectin telehealth prescription mill.

The point is, state medical boards, given their lack of resources, tend to go after the “low hanging fruit,” cases they can win without the expenditure of a lot of resources, cases like physicians impaired by substance abuse or physicians sexually abusing patients under the guise of medicine. As I once put it years before the pandemic:

…as Dr. Lipson pointed out, state medical boards are notoriously toothless. Think about it. How many times has the Texas Medical Board gone after Stanislaw Burzynski over the last 38 years and failed? Or what about the quack whose friendship with the town sheriff led to the identification of the nurses who complained about him and their suffering severe professional and legal consequences as a result? Or what about the neurosurgeon who can’t operate and injured many patients? Or what about the oncologist who administered chemotherapy to patients without cancer and administered medically-unnecessary chemotherapy to patients with cancer? So bad was his behavior that a nurse interviewing for a job noticed that the chemotherapy was being mixed up incorrectly and complained to the state medical board with no result. This oncologist was only brought down when the feds investigated massive Medicare fraud. Second, medical boards need a concrete complaint, and that concrete complaint usually has to be about the actual practice of medicine. The Arizona Board, for example, might list 49 definitions of unprofessional conduct, but try fitting speaking out about vaccines into any of them. In Dr. Wolfson’s case, one might tag him under #19, “any conduct or practice contrary to recognized standards of ethics of the osteopathic medical profession.” Maybe.

The bottom line is that state medical boards tend to be toothless, underfunded, and overwhelmed. That’s why the only physician behaviors very likely to result in strong action consists of running a prescription mill, diddling patients, or practicing while impaired by abuse of alcohol or illicit substances. It’s a matter of resource allocation and prioritization. State medical boards tend to react primarily to what they perceive to be the most immediately and obviously dangerous behaviors. Practicing quackery rarely makes the cut, because medical boards are loathe to make value judgments about medical practice, and proving quackery is way harder and more resource-intensive than proving a doctor is an addict practicing while impaired or that he’s diddling patients. Even horrible surgeons like Dr. Duntsch, whose epic incompetence in the operating room resulted in multiple “clean kills” and so-alarmed colleagues that they actually took the rare action of complaining about him, all too often take a long time to take down.

Adjudicating whether a given treatment (or off-label use of an FDA-approved drug) is quackery and sufficiently below the accepted standard of care or not to warrant discipline is something that they are much more reluctant to do because, again, quacks often have a lot of resources to argue, delay, and claim that their treatments aren’t quackery, as Drs. Buttar and Burzynski used to do routinely decades ago.

Another point came up in the story’s discussion of the case of Massachusetts physician Dr. John Diggs, who faced discipline for “prescribing ivermectin and hydroxychloroquine to a patient with covid symptoms who died in 2022 after being intubated”:

The board alleged that Diggs prescribed the medications despite “clear evidence for the lack of any clinical benefit of hydroxychloroquine” and the fact that “ivermectin has been proven ineffective.”

The medical board accused Diggs of providing treatment to two patients that fell “below the standard of care.” It also accused him of “disseminating misinformation” on a Worcester, Mass., radio program in December 2020 when he promoted unproven coronavirus treatments touted by the alliance. At least two physicians lodged complaints in 2021 accusing him of “physician misconduct related to egregious COVID-19 misinformation and medical care well outside of the standard of care” and alleging “significant risk of patient harm,” board records show.

In documents detailing his response to board charges, Diggs denied disseminating misinformation on the radio program but admitted to prescribing ivermectin and hydroxychloroquine and advocating for treatment of covid based on “studies from recognized medical professional organizations.” His lawyer, in the documents, accused the board of violating Diggs’s free-speech rights by “attempting to inhibit the expression of his medical opinions.”

While I realize that it is a tricky line between professional and personal speech, I have frequently argued that professionalism in medicine includes not spreading misinformation. Of course, it is far less difficult to take action against a physician practicing quackery than it is to do so against a physician simply spreading COVID-19 misinformation and not treating patients using interventions based on that misinformation, and Dr. Diggs was, in my opinion, treating patients with quackery, ineffective treatments against COVID-19, and then trying to absolve himself of responsibility by disingenuously blaming COVID-19 for their deaths, as if they were like patients who die in spite of being given effective treatment rather than patients given false hope by his promotion of ineffective treatments. This is a frequent theme among COVID-19 quacks:

Some of the doctors cited in the misinformation-related complaints have defended their actions by saying they adhered to covid-treatment guidelines recommended by organizations that promote alternative therapies — guidelines rejected by major medical societies and government agencies. They said patients died of covid — not because of misinformation or the therapies they provided.

“Organizations that promote alternative therapies”? Does that sound familiar? It should. It’s what we’ve been warning about for 15 years, fake medical societies that promote unscientific or pseudoscientific quackery, or, as Dr. Atwood once called them, pseudomedical pseudoprofessional organizations (PPOs) back in 2008. Since the pandemic, the PPO has, if anything, flourished more than any of us could ever have predicted. Just as they were wielded by quacks in 2008 against state medical boards and in favor of legalizing and regulating quack professions like naturopathy, in the age of COVID-19 these PPOs have become major forces for defending antivaccine misinformation and COVID-19 quackery against attempts to discipline doctors. Add to that the political polarization that has led those largely of a certain political persuasion to side with the COVID-19 pandemic minimizers, quacks, and antivaxxers, and state legislators are working to make the jobs of state medical boards even more difficult by placing restrictions on their ability to consider disciplining COVID-19 misinformation spreaders, decreasing their funding, and worse. One can understand how state medical boards, particularly in states with legislatures controlled by physicians of such a political bent, might be reluctant to risk incurring the wrath of the government by pursuing cases against COVID-19 quacks and misinformation spreaders, or, as the Post reports:

As of June, medical boards in at least 14 states had taken disciplinary action against one or more physicians for misinformation-related causes, The Post’s analysis shows. Nine of those states have Democratic governors, leaving more-conservative swaths of the country unprotected given that board members are usually appointed by the governor, subjecting them to political head winds.

And:

In the last two years, Missouri, North Dakota and Tennessee have passed laws that would protect doctors from disciplinary actions for prescribing ivermectin, according to The Post’s review of more than 80 bills, including those identified by the Federation of State Medical Boards, the Association of State and Territorial Health Officials and the Center for Public Health Law Research at Temple University.

And:

In addition, attorneys general in six states — Indiana, Kansas, Nebraska, Oklahoma, Tennessee and South Carolina — have issued opinions saying doctors can prescribe ivermectin and hydroxychloroquine, with four of them determining doctors cannot be disciplined for off-label prescription to treat covid.

You get the idea. Moreover, the passage of laws designed to legitimize COVID-19 quackery is nothing new either. I (and others) have been warning about the phenomenon since 2008. For example, in California there was SB 577, a bill was passed and signed into law back in 2002 designed to regulate alternative medicine practitioners. Basically, it allows the practice of medicine without a license, as long as the practitioner provides clients with a clear statement that he is not a licensed physician, a list of services provided, and a description of training. California is by no means alone, either. Jann Bellamy has pointed to bills and laws that she refers to as the quack full employment act (Colorado) and “quack protection law” (Nevada). Such are the fruits of the “health freedom” movement and the increasing acceptance of pseudoscience that prosecutors, state medical boards, and the police have a hard time prosecuting and convicting even the most egregious quacks. Add to that an insufficiently-rigorous and poorly-funded regulatory structure in most states, coupled with excessive deference to the prerogatives of physicians, and what is happening now is no surprise to those of us who have been documenting these problems for many years, particularly when you consider that most state medical boards can’t even begin to investigate a physician until and unless there is a complaint filed about that physician’s treatment of a patient or patients.

The Post story includes a litany of doctors whom state medical boards in various states have tried to hold to account for treating patients with ineffective and unapproved treatments and/or spreading COVID-19 misinformation, including names we’ve discussed here before, such as Dr. Maryl Nass, Dr. Ryan Cole, and Dr. Steven La Tulippe, and others that we have not, such as the aforementioned Dr. Diggs, as well as Wisconsin physician Dr. Edward Hagen and Nevada physician Dr. Medina Culver, the latter of whom brings me to a puzzling point.

Why don’t victims sue COVID-19 quacks?

I’ll finish by discussing Dr. Culver, who, according to the Post story, is currently the defendant of a malpractice suit, something that is unfortunately relatively rare when it comes to victims of quacks, be they COVID-19 quacks now or cancer quacks like Stanislaw Burzynski over the last four and a half decades:

In Nevada, Jelena Hatfield and her husband, Jeremy Parker, did not believe what federal health officials said about the safety or effectiveness of the coronavirus vaccines and refused to get a shot.

Instead, Hatfield said the couple sought what Trump had touted early in the pandemic as an alternative way to protect themselves: hydroxychloroquine. After Trump’s repeated promotion, the FDA issued an emergency-use authorization in March 2020 allowing the antimalarial drug to be used to treat covid. By early June of that year, however, virtually every published study reported that the medication was not effective in reducing death or illness, and the FDA revoked its authorization because of reports of serious side effects, including heart problems.

But a year later, Medina Culver, a family medicine physician in Henderson, Nev., prescribed hydroxychloroquine to Parker as a preventive treatment during a telehealth visit, Hatfield said. She said that Parker had connected with Culver through America’s Frontline Doctors, which shot to prominence in 2020 by challenging pandemic health guidance, and that the doctor never performed a physical exam of her husband.

In January 2022, Parker began having cold-like symptoms, assumed he had contracted covid and, unbeknown to his wife or Culver, took the medication that he had stashed away. The 52-year-old construction worker died within days, Hatfield said.

TIME Magazine reported on the case in May 2023, and it turns out that Jeremy Parker was the victim of a telehealth grift run by America’s Frontline Doctors :

The previous summer, Jelena discovered, Jeremy had started following AFLD online after listening to podcasts that promoted conspiracies about COVID-19. At the time, the group was producing slick videos on social media, falsely claiming that U.S. health agencies were withholding life-saving treatments, and that doctors refusing to prescribe them were like “good Germans who allow the Nazis to kill the Jews.” Jeremy, who worked as an industrial sandblaster, became convinced that hydroxychloroquine and ivermectin were the only effective treatments for the virus.

On Aug. 26, 2021, Jeremy paid $90 for a consultation through AFLD’s online telemedicine portal. He was connected to a doctor named Medina Culver, 33, an osteopathic physician and Instagram influencer based in Henderson, Nev. Culver did not see or examine Jeremy. Over the phone, she prescribed him hydroxychloroquine for COVID-19 treatment or prevention, according to a receipt reviewed by TIME. Soon after, Jeremy received a prescription for 200mg of hydroxychloroquine in the mail from Ravkoo, a Florida-based pharmacy chain partnered with AFLD. According to his widow’s lawsuit, he took those hydroxychloroquine pills the night he died.

Jeremy’s family is suing both AFLD and Culver in Nevada district court for in excess of $30,000 in damages. The lawsuit, which was filed in February on behalf of his estate and cites TIME’s 2021 investigation, alleges that his death was linked to the falsehoods spread by AFLD as well as the doctor who prescribed it. “They didn’t even examine him. They gave him something that he used as they prescribed, and it killed him,” Jelena Parker-Hatfield says. “How can they not be held accountable for something? How in America can this be a system that works, that everybody is okay with?”

This is a good question. After all, what is being described sounds an awful lot like the telehealth ivermectin and hydroxychloroquine prescription mill grift that AFLD was running in 2021, right down to the use of the Ravkoo pharmacy chain to fill the prescriptions and the $90 charge for a telehealth consultation. It was a scam uncovered through investigations by TIME Magazine and The Intercept in 2021. What is depressing, though, is that the family is only suing for $30,000, which is not very much to AFD and many other grifting COVID-19 quacks, many of whom have profited handsomely from their activities during the pandemic, as documented by TIME Magazine.

As a physician, I will confess that I generally have a relatively dim view of most malpractice suits, as there are many that are dubious. On the other hand, I’m probably more open than a lot of other doctors to such suits when there is legitimate malpractice, and to me recommending ivermectin or hydroxychloroqine by telehealth instead of vaccination to prevent COVID-19 is definitely practicing so far below the standard of care that it should qualify as malpractice; so I fully approve when victims of quacks sue for malpractice. It’s just that it so rarely seems to happen. This is an observation that is not just true now but was true long before the pandemic.

Indeed, a discussion of this very issue came up in the comments after one of my posts about Stanislaw Burzynski and Robert O. Young as poster children for failures of states to rein in quacks. In Burzynski’s case, there is a cap in Texas on judgments on punitive damages above $250,000, making such cases less attractive for attorneys to take on contingency. Bob Blaskiewicz, for instance, noted that Burzynski has settled out of court and that one of plaintiffs, being a patient with advanced cancer, unfortunately died before the case could go to trial. Moreover, most malpractice suits are lost, and in the case of malpractice suits against quacks it is likely to be difficult overcoming the likely argument by the defense that the patient made the choice not to vaccinate and instead choose “alternative” treatments like ivermectin and hydroxychloroquine. It is often difficult to determine what patients were and were not told about such treatments, as well.

The bottom line is that now, as in years past, state medical boards are largely toothless when it comes to regulating the practice of medicine and stopping dangerous doctors from endangering patients. The unfortunate bottom line is that the long history of efforts by the health freedom movement to eliminate any effective enforcement of the standard of care in medicine, the antivaccine movement to shield antivax doctors and legitimize their quackery, and right-to-try advocates to weaken the FDA have led to the current situation in which most quacks, be they COVID-19 misinformation pushing quacks or old school quacks (the two becoming less and less distinguishable by the year) are pretty safe from investigation or discipline by their state medical boards. This was true before the pandemic, and I like to cite the example of Dr. Farid Fata, an oncologist who administered chemotherapy to patients who did not have cancer in order to defraud Medicare and Medicaid to the tune of $35 million over several years. It wasn’t the Michigan Board of Medicine that put a stop to his intentionally misdiagnosing patients in order to justify treating them with expensive chemotherapy; it was the feds investigating Medicare and health insurance fraud.

Until there is the political will to empower state medical boards to go after quacks, again be they COVID-19 quacks or any other quack, and provide the resources to them to be able to do so without risking starving their other important activities of funding, it unfortunately appears that a patient’s best defense is a healthy skepticism, as in “let the patient beware,” which is very difficult given the differential in medical knowledge between physicians and their patients, with the most likely means of punishing such doctors being to sue them for malpractice after they have injured a patient. Even more unfortunately, that is a hard road that frequently fails, and I don’t see the political landscape changing any time soon to allow state legislatures to properly empower and fund their state medical boards. We should be putting the pressure on our representatives to do just that.