[Orac note: Yes, Orac decided to be lazy and continue recharging his Tarial cells last week. He did, however, update and expand this recent post about the ABIM and COVID-19 misinformation from a certain not-so-secret-other blog for your edification. His contemplation of all data led him to things that he missed a week ago that led him to change the emphasis and add more about Dr. Paul Marik. Regular Insolence will resume this week.]
Recently, I wrote what was basically a lament and jeremiad about the longstanding failure of state medical boards to discipline quacks and antivax doctors. It is, as I discussed, a failure that dates back to before the pandemic, which is why I described how the pandemic had exposed the toothlessness of most state medical boards. My observation was based on a recent story published in The Washington Post by Lena Sun, Lauren Weber, and Hayden Godfrey that described how few physicians spreading misinformation about COVID-19 and vaccines had suffered anything in the way of discipline or penalties, much less actually had their medical licenses revoked, despite the unfortunately huge numbers of physicians who have made a name for themselves on social media for spreading fear, uncertainty, and doubt about public health interventions, treatments, and vaccines for COVID-19, with many of them selling quackery such as “spike protein detox” instead. As you might expect, I pointed out that this has been a longstanding problem with state medical boards, which are often understaffed and underfunded, incentivizing them to deal with easy, imminent threats, like doctors with substance abuse disorder, rather than cases where they have to adjudicate a standard of care an possibly devote large amounts of their limited resources to take on well-funded quacks like Stanislaw Burzynski and Rashid Buttar.
Given that I had just written about the topic of holding misbehaving physicians accountable for the harm that they do, naturally it caught my attention when I saw this Tweet a week ago from journalist Anna Merlan citing an email blast from the what is in my opinion a quack medical group, the Front Line COVID-19 Critical Care Alliance (FLCCC Alliance) about a decision apparently made by the American Board of Internal Medicine (ABIM):
Curious, I went to the FLCCC Alliance website and Substack, where I was greeted with headlines like Two Leading COVID-19 Doctors are Facing Accusations of Spreading Misinformation by American Board of Internal Medicine (ABIM) Committee and FLCCC Doctors Plan to Fight Board Decision. It didn’t take long for allies of Drs. Pierre Kory and Paul Malik to weigh in, in particular Sen. Ron Johnson:
Many of you will recognize the video as a brief “greatest hits” of COVID-19 misinformation, complete with the bogus “Pfizer whistleblower” conspiracy theory and a bit at the end about “looking at the evidence for myself.” Regular readers of SBMand my not-so-secret-other-blog know my opinion of FLCCC, namely that they’re a bunch of rank quacks who made their name selling ivermectin as a “cure” for COVID-19. Unfortunately, there are a lot of ideological useful idiots in positions of power who have portrayed the FLCCC as a group of “brave maverick doctors”—”truth tellers”—and tried to alter the law to shield them from the consequences of the misinformation they spread and the quackery they practice, even as they were part of a network creating a global market for health fraud selling ineffective repurposed drugs like hydroxychloroquine and ivermectin to treat COVID-19.
Indeed, in retrospect, I had noticed a rare email from ABIM sent to my work address a couple of days before Merlan’s Tweet, which made me wonder if something was up. Here’s a rather generous excerpt, given that it’s an email blast:
Second, I wanted to provide an update on our work around addressing medical misinformation. I’m sharing a piece just published in JAMA that I coauthored with Dean Schillinger, MD, Professor of Medicine in Residence at the University of California San Francisco, titled “Health Communication Science in the Balance.”
In it, we explore how and why the NIH abruptly “paused” a new $154 million research program called Advancing Health Science Communication and Practice—which was 20 months in the making—with only a vague explanation that they needed to “reconsider the scope and aims in the context of the changing legal and regulatory landscape related to communication platforms.”
It should be noted that this announcement was made June 6, 2023, just weeks ahead of a judicial order issued on July 4 in the Missouri v. Biden legal case that prohibits governmental agencies from talking with social media companies. Judge Terry A. Doughty’s order has been stayed temporarily by the Appellate Court, but it appears to have already had an impact on federal officials.
At a time when trust in the medical profession is at an all-time low, we know patients seek guidance about their health from a wide variety of other sources, including social media platforms. It is a tremendous disservice to patients everywhere when agencies like the CDC cannot even have a conversation with social media companies about how to ensure that evidence-based medical information is easily identifiable and distinguishable from snake oil.
It also hampers our collective ability across all sectors of health care to collaborate on initiatives that may help mitigate misinformation and elevate expert voices. I wrote about one such potential private-public partnership model in a piece in the Annals of Internal Medicine that you may have seen, called Addressing Viral Medical Rumors and False or Misleading Information.
In closing, I’d also like to share a recent article in the Washington Post, where reporters Lena Sun, Lauren Weber (of the Post’s misinformation team), and Hayden Godfrey undertook a comprehensive investigation of disciplinary actions taken by medical boards across all 50 states, concluding that “doctors who jeopardized patients’ lives by pushing medical misinformation during the pandemic and its aftermath have faced few repercussions.”
It’s truly a remarkable piece of journalism, and while it speaks specifically to the challenges that state medical boards are confronted with in our current environment, I’m sure we can all see aspects of ourselves and the organizations we serve in this story. It shouldn’t surprise any of us if this isn’t the last story we see like this.
First of all, the fact that political pushback seems to have shelved the $154 million research program called Advancing Health Science Communication and Practice shows just how powerful the forces promoting misinformation and resisting any effort to counter it have become. In its article listed above, the ABIM asks, “What does the ‘current regulatory and legal landscape around communication platforms’ refer to, and why does it matter?” I assume that these are rhetorical questions, as it is pretty obvious to me what they refer to and mean—and why they, unfortunately, do matter. Basically, to me it sounds as though the NIH caved to political pressure from Republicans like Sen. Ron Johnson.
Be that as it may, I did wonder from the ABIM email blast whether something was up or not, given how seldom I’ve received these emails, and apparently I was correct. The ABIM has apparently decided to take its first concrete action against FLCCC members Dr. Paul Marik and Dr. Pierre Kory. But what does this all mean? Let’s start with Merlan’s VICE article published a month and a half ago, Fringe COVID Doctors Say They’re Under Attack by Medical Certification Board.
Spoiler alert: It’s not as all clear whether the ABIM has actually done anything with respect to Dr. Kory’s or Dr. Marik’s board certifications—or, come to think of it, Dr. Peter McCullough’s.
The grifters’ “persecution” narrative
If there’s one thing that cranks, quacks, and grifters have long known, it’s that somehow being able to portray oneself as a “victim,” as “persecuted,” is the most effective way to rally followers and promote the grift, and FLCCC is no different. As Merlan reported:
In the ongoing saga of the ivermectin guys, who claim they alone hold the extremely dubious cure for COVID, it’s necessary to have an antagonist—someone they can say is threatening them for exposing the truth. Recently, it’s been the American Board of Internal Medicine, or ABIM.
Two prominent vaccine skeptics and promoters of unproven COVID treatments, Drs. Pierre Kory and Peter McCullough, said on Twitter that the board is threatening them for their work. This narrative has speedily picked up speed across the right-wing ecosystem, with one right-wing website claiming the board is going to “revoke their medical licenses,” which is not something the ABIM can do. The whole thing is a useful view into how mainstream medical bodies are struggling to deal with their still-certified but increasingly out-there colleagues. And it’s a very instructive example of how fringe medicine promoters—and their allies in Congress—immediately spin their tangles with the medical establishment into more fame and attention.
This strategy works even better if it’s coupled with pugnaciousness and a vow to “fight” the “oppressor”:
It was basically, the “Debate me, bro!” tactic so beloved of cranks, quacks, and conspiracy theorists disingenuously employed. I say “disingenuously” because no doubt Drs. Kory and McCullough know that the ABIM probably couldn’t do this even if it wanted to, because it would be arguing an individual case in public. Just remember that this wasn’t a serious proposal. It was all performative, as the clip from the movie Braveheart included by Dr. McCullough in his quote-Tweeted Tweet above shows:
I suppose I should be grateful that Dr. McCullough refrained from using the clip of Mel Gibson’s rendition of William Wallace’s inspirational speech to his troops before battle with the English or maybe even of Wallace’s execution, when, instead of taking the quick and merciful death promised him if he were just to ask for “mercy,” he cries out “Freedom!” as he is being tortured and disemboweled. (I was half-tempted to issue a spoiler alert, but then realized that the movie is 28 years old. Deal with it.) Basically, the martyr complex is an essential element to all good quack grifts. (Burzynski was a master of it, for example.) It doesn’t matter that, in countering charges that they are spreading misinformation, they spread misinformation:
The current situation began when McCullough, a cardiologist formerly employed by Baylor Hospital who’s become a vocal vaccine skeptic, and Kory, a co-founder of the ivermectin-promoting Frontline Covid-19 Critical Care Alliance, or FLCCC, both said that they’d received threatening letters from the ABIM, saying it was considering disciplinary sanctions against the two men from promoting misinformation. This immediately became a fairly big deal on the COVID-skeptical and ivermectin-promoting right, and the publication American Greatness immediately claimed that the body was threatening to “revoke the medical licenses” of both men.
That is, as a point of order, both wrong and very dumb: The ABIM is a certification body, not a licensing one. The ABIM certifies doctors who specialize in internal medicine and other subspecialties; that certification proves they completed a residency in their specialty and also passed a specialized exam.
This is a common misunderstanding among the public about the difference between medical licensure and board certification. In order to practice medicine, you do have to be licensed by the state in which you practice. However, you can get a medical license after just medical school and one year of internship. In general, however, to practice you also have to have completed an accredited residency in a medical specialty. Board certification involves the board for that medical specialty “certifying” that you have (1) successfully completed an accredited residency in the specialty and (2) completed a test that demonstrates a basic level of knowledge and competency in the specialty. For my specialty, the American Board of Surgery (ABS) required passing a written qualifying examination, after which I then had to pass an oral certifying examination. After that, I had to recertify every ten years by passing a written examination. It is true that the ABS has, since my last recertification, created a new track that doesn’t involve taking a test on all of general surgery, the way I did twice before after my initial board certification but rather involves self-learning, documentation of continuing medical education, case logs, and smaller, specialty-focused tests every three years. (That is the track to which I will switch when my current ten-year board certification expires in a few years.) In the medical specialties overseen by ABIM, the process of maintaining board certification can be much more involved, including submitting patient evaluations, which has led to a fair amount of resistance and pushback from physicians chafing under the requirements.
It is not my intention to comment on the process itself beyond this, but rather to explain what board certification is. Also, most hospitals will not provide privileges to a physician who is not board-certified by an accepted, recognized board, nor will insurance companies reimburse for services provided by such doctors. Of course, the wag in me can’t help but wonder why Drs. Kory and Marik are so upset given that they both appear to have abandoned traditional medical practice in which they might want to have hospital privileges and bill insurance companies and Medicare for their services in favor of the model preferred by “brave maverick doctors” who don’t practice according to science-based guidelines or scientific consensus: Cash on the barrelhead fee-for-service, no insurance accepted. As far as their livelihood goes, even if the ABIM does revoke their board certifications, the action is unlikely to have much, if any, financial impact on them. They even admit it in their response:
The loss of ABIM certification will not impact Dr. Kory or Dr. Marik’s ability to practice medicine or conduct scientific research or educational work. Some hospitals and healthcare providers require ABIM certification for employment, however the certification is not required by state medical boards or for a medical license anywhere in the U.S.
Seriously. When you’re a quack who doesn’t take insurance and no longer has hospital privileges, board certification is unnecessary. Neither of these doctors is practicing in an environment where board certification is even required! However, the narrative of the poor victim persecuted by big government, big tech, big pharma, and big medicine must be maintained, hence the outrage from FLCCC Alliance and Drs. Kory and Marik. Also, I’m pretty sure that there is also likely an element of pride involved, in which the likelihood of soon having something as important as their board certification revoked injures their massive egos.
In addition, Sen. Ron Johnson was at it again after the initial letter in June, publishing an open letter to the ABIM containing another “Debate me, bro!” challenge to the ABIM, even inviting ABIM representatives to one of his COVID-19 “roundtables”:
Unfortunately, the federal health agencies, public health experts and vaccine manufacturers did not accept my invitation to either event. Rather than engage in a public dialogue in which information and perspectives can be openly exchanged and debated, the individuals and organizations responsible for our pandemic response continue to attack and discredit those with a different perspective by using the vague pejorative of “spreading misinformation”.
It is well last time for the public to hear from many sides regarding COVID-19 in a public forum. The purpose of this letter is to invite you, members of your Credentials and Certification Committee, and any other medical expert of your choosing to come to Washington and engage in an open and honest interchange regarding all aspects of COVID-19, without the threat of reprisal by the ABIM or any other organization. I request your participation in a public forum on one of the following dates: July 26, July 27, July 29, August 2 or August 3.
It is also telling that Dr. McCullough didn’t announce the ABIM letter himself first, but rather appears to have just forwarded it to Sen. Johnson, who used it as a tool to promote his misinformation-packed COVID-19 roundtable events.
Also, from the wording of the letter quoted by the FLCCC Alliance, the ABIM hasn’t even actually officially revoked Dr. Marik and Kory’s board certifications yet. Before concluding that, in “accordance with ABIM bylaws, Dr. Marik and Dr. Kory will appeal the committee’s recommendation,” FLCCC rants:
The ABIM Credentials and Certification Committee has recommended that FLCCC co-founders, Paul Marik, MD and Pierre Kory, MD, MPA should have their ABIM certifications revoked for spreading what the committee considers “false or inaccurate medical information.” The committee concluded that the published peer-reviewed, clinical, and observational data that create the foundation of FLCCC protocols, educational materials and public statements are not “consensus driven scientific evidence.” In reaching their recommendation, the committee cites NIH and CDC guidelines as well as several studies that have been largely disproven or questioned for their glaring flaws, conflicts of interest or poor design. Additionally, the committee cites a National Public Radio story that was later corrected for falsely reporting that overdosing of ivermectin was causing a surge in emergency room admittance.
“What ABIM is doing is basically telling doctors that we need to take our orders from bureaucrats in Washington and certain medical journals instead of making treatment decisions based on our training and expertise,” said Pierre Kory, MD, MPA, president and chief medical officer of the FLCCC. “Threatening doctors the way the ABIM is doing, simply degrades the practice of medicine to be something that is done out of fear rather than to heal our patients in the best way we know how.”
“The ABIM is doing this to us and other doctors who didn’t follow what the committee is calling ‘consensus’ as a way to scare others into silence,” said Paul Marik, MD, chairman and chief scientific officer of the FLCCC. “Following the ABIM’s ‘consensus’ will only deprive patients of important treatments that have saved lives all over the world.”
The ABIM committee continues to spread the myth that ivermectin is dangerous without critically examining the scientific and clinical evidence. In its statement the committee cites false claims that ivermectin could be “fatal” while never mentioning the 99 controlled trials – 46 of them randomized controlled trials – that showed ivermectin is highly effective in treating COVID-19 with little to no reported side effects. These trials include over a hundred and thirty thousand patients successfully treated with no severe side effects, consistent with the WHO’s finding that ivermectin ranks higher in safety than Tylenol or aspirin.
Ivermectin is indeed safe and effective when used to treat roundworm infections. The problem, of course, is that it doesn’t work for COVID-19, those “randomized controlled trials,” many of them fraudulent, not withstanding. It was always predictable that ivermectin would be highly unlikely to work as a treatment for COVID-19 just on pharmacology. As I like to point out, the concentration of ivermectin that inhibited the replication of SARS-CoV-2, the coronavirus that causes COVID-19, in cell culture was 50- to 100-fold higher than what can be safely achieved in the human bloodstream using “safe” ivermectin dosing. There’s a reason that I’ve referred to ivermectin as the “acupuncture of COVID-19 treatments” and pointed to it as an example of why science-based medicine is important not just for low plausibility alternative medicine treatments but for low plausibility treatments of all kinds—like ivermectin for COVID-19.
Also, what the FLCCC Alliance conveniently fails to mention is that the promotion of ivermectin as a cure-all for COVID-19 has indeed led people to use veterinarian formulations designed for large animals like horses and cows. As I like to point out, equine ivermectin comes packaged in syringes with “1.87% ivermectin paste. 6.08 g syringe treats up to 1,250 lbs. Safe for horses of all ages, pregnant mares, breeding stallions.” Another formulation comes as a 1% solution to be given 1 ml/110 lbs of weight. Basically, in horses the dose of ivermectin can be up to 1.200 mg, while the human dose recommended is only around 3 mg. When ivermectin promoters state that ivermectin is “very safe” in humans, they are correct, but only at the dose recommended for humans. As with many drugs, toxicity increases with increasing dose, and when you take far more than the recommended dose your risk of serious side effects increases. Fortunately, most of these side effects have been mild, but even mild side effects are too much to risk for a drug that doesn’t work. Worse, promotion of ivermectin for COVID-19 has, predictably, expanded to its being touted for cancer and even autism. The FLCCC will, of course, claim that they have never promoted ivermectin for such purposes, but their ally Tess Lawrie has. Promoting a drug—any drug—as a near-miraculous cure for one life-threatening disease will almost always lead other quacks to promote it for other conditions and diseases.
Free speech versus board certification
I will conclude by discussing how the FLCCC is also bemoaning the recommendation of the ABIM Credentials and Certification Committee to strip Drs. Kory and Marik of their board certifications as an attack on “free speech.” This is, of course, a lament that quacks throughout the decades that I’ve been writing about science-based medicine vs. quackery nearly always invoke whenever they are criticized or a medical authority tries to hold them accountable for their quackery. The FLCCC is no different. Consistent with the narrative of their conspiracy theories in which ivermectin is the “safe and effective” miracle cure for COVID-19 that “they” don’t want you to know about, there must be nefarious forces seeking to silence the FLCCC’s two heroic doctors who are only fighting for their patients. Seriously, I kid you not. You can buy merch on the FLCCC website with images of Drs. Marik and Kory like these:
Seriously, this is a bit too much, even for me, and over the years I’ve seen so many brave maverick doctors portraying themselves as the heroes in an Ayn Rand novel.
It’s exactly the same narrative that Stanislaw Burzynski has employed for 45 years whenever the FDA or the Texas Medical Board made their feeble efforts to hold him accountable and that Dr. Rashid Buttar used back in 2008, when he called the North Carolina Medical Board a “rabid dog” for trying to “silence” him. It’s the same claim that quacks make about bills designed to strengthen state medical boards to act when physicians spread dangerous misinformation.
Unfortunately, it’s a very effective ploy. All too many of my colleagues chafe at any suggestion that they can be told how to practice medicine. Even though three years of a pandemic that’s killed over one million people in just the US alone has finally awakened regulatory agencies like state medical boards and professional societies to the the severity of the problem of doctors using their professional status to spread misinformation, unfortunately, we as a profession have a lot of members who either can’t or don’t want to see it as a problem and for whom the FLCCC’s defense resonates. I suspect that the reason now is similar to the reasons before the pandemic, 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 or specialty 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. Indeed, one mistake in framing that I see from the ABIM and state medical boards is to emphasize too strongly “spreading misinformation” as a reason for action, rather than the quackery. What physicians say will always draw a “free speech” defense. What they do—i.e., how they treat patients—is a lot less defensible and more strongly a basis for state medical boards and specialty boards to take action.
Professionalism, however, is essential to medicine, and one of the elements of professionalism is not to practice quackery or to recommend quackery, and, if there’s one thing I’ve observed, it’s that the practice and promotion of quackery almost always go hand-in-hand. In other words, physicians promoting medical misinformation (like the FLCCC) rarely just promote medical misinformation. They almost always practice what they preach, so to speak; i.e., practice quackery. After all, FLCCC doesn’t just recommend ivermectin, hydroxychloroquine, and its various and sundry “early treatment protocols” that don’t work, its members use them to treat COVID-19 patients—and are proud that they do so! It is true that the First Amendment gives physicians like Drs. Marik and Kory the freedom to say whatever they want about COVID-19 and its treatment, no matter how quacky, but it doesn’t mean that they can do so without consequences, which can be loss of board certification when their professional speech and actions wander too far outside of what can be justified with science. Revoking the licenses and board certifications of such physicians is quality control and consumer/patient protection, not “censorship.” These doctors are still free to say whatever they want, no matter what the ABIM does.
But did ABIM actually do anything?
Coming back to the spoiler alert above, let me just say that it is unclear that the ABIM has actually done anything at all yet in response to the copious amounts of COVID-19 misinformation and quackery coming from these three doctors. All the cries of “Persecution!” could well be performative about what the ABIM might do. I went to the ABIM website to check on the board certification status of all three doctors, Drs. Kory, McCullough, and Marik. What did I find? Well, both Drs. Kory and McCullough are both listed as board-certified and participating in the ABIM maintenance of certification program, with Dr. McCullough listed as certified in internal medicine and cardiology and Dr. Kory certified in internal medicine and pulmonary and critical care medicine. What about Dr. Marik? His certification is listed as “inactive,” whatever that means. Actually, the ABIM tells you what it means right on the page you use to check a physician’s board certification status:
Physicians are publicly reported as inactive if they were once certified by ABIM but now, for non-disciplinary reasons, they no longer have an active medical license in any jurisdiction.
Translation: For whatever non-disciplinary reason, Dr. Marik no longer holds a valid active medical license, and so his board certification is “inactive.” I was curious; so I did a little Googling and learned from MedPage Today that Dr. Marik let his medical license expire a little over a year ago:
Paul Marik, MD, one of the founding members of the Front Line COVID-19 Critical Care Alliance (FLCCC), which has touted ivermectin as a treatment for COVID-19, has let his medical license expire.
The critical care physician’s license was issued on July 1, 2009, and it expired last week on June 30, according to the Virginia Department of Health Professions’ online database. The license was limited to universities, permitting Marik to practice in a university or related setting.
The announcement of Marik’s resignation was preceded by a lawsuit that the physician had previously filed against Sentara Healthcareopens in a new tab or window in Virginia over its ban of certain treatments for COVID-19. The suit was filed on the same day that the Journal of Intensive Care Medicine retracted an article that Marik co-authored on his MATH+ Hospital Treatment Protocol for COVID-19, which includes ivermectin. The retraction notice cites a communication the journal had received from Sentara that raised “concerns about the accuracy of COVID-19 hospital mortality data reported in the article.”
I will admit to being unfamiliar with Virginia’s including a restricted license that allows a physician to practice only at an academic medical center. It almost reminds me of restricted licenses given to trainees like interns and residents under the auspices of the hospital where they are training. Whatever the details, I can’t help but wonder why Dr. Marik’s license was restricted that way rather than being a fully restricted license to practice medicine.
So why did Dr. Marik have this restriction? It turns out that ivermectin quackery for COVID-19 was not his first kerfuffle with medical authorities. He had entered into a consent agreement in March 2021 for having prescribed controlled substances that included tramadol, phenobarbital, oxycodone, diazepam, and alprazolam to people “absent a bona fide practitioner-patient relationship” over a time period from 2016 to 2020.
As for Dr. Marik, he made excuses:
This week, in response to an inquiry from MedPage Today regarding the expiration of his license, Marik confirmed in an email that he is not currently practicing medicine.
“My academic license was limited to working at EVMS and ended when I chose to retire at the end of December, 2021,” Marik wrote. “I did not renew my limited license with another institution and have no plans at this time to obtain a license.”
Marik said that the expiration is not related to a March 2021 skirmish over his license. At that time, the Virginia Board of Medicine and Marik entered into a consent order, which stated that “outside the limits of his license and absent a bona fide practitioner-patient relationship,” Marik prescribed controlled substances to a handful of individuals.
In other words, by summer 2022, Dr. Marik appears not to have needed to practice medicine anymore and decided to fully embrace the grift of FLCCC as his primary source of income after resigning from his faculty position at Eastern Virginia Medical School after he had filed a lawsuit against Sentara Health over its banning of his ivermectin “early treatment” protocol for COVID-19.
Whatever the ABIM ends up doing or not doing—and, make no mistake, it appears to have done nothing truly substantive yet about any of these quacks—I only wish that state medical boards would do something that would really make a difference: Take away their medical licenses. Yes, I said it, and I meant it: Take away their medical licenses.