I can’t speak for anyone else who blogs here at Science-Based Medicine, but there’s one thing I like to emphasize to people who complain that we exist only to “bash ‘alternative’ medicine.” We don’t. We exist to champion medicine based on science against all manner of dubious practices. Part of that mandate involves understanding and accepting that science-based medicine is not perfect. It is not some sort of panacea. Rather, it has many shortcomings and all too often does not live up to its promise. Our argument is merely that, similar to Winston Churchill’s invocation of the famous saying that “democracy is the worst form of government except all the others that have been tried,” science-based medicine is the worst form of medicine except for all the others that have been tried before. (Look for someone to quote mine that sentence soon.) It’s not even close, either. SBM has produced far and away better results than any form of medicine that has come before it, which is why it’s always puzzled me that so much of “alternative” medicine seems to be a throwback to ancient, pre-scientific, sometimes religion-based medical systems that existed in the days before germ theory and a rudimentary understanding of human physiology. After all, it wasn’t until William Harvey in 1626 that doctors even knew for sure that there was a direct connection between the arterial and venous system, for example, and the sphygmomanometer wasn’t invented until 1881. Monitoring blood pressure didn’t become routine until the early 20th century, and monitoring the diastolic blood pressure wasn’t routine until the 1920s.

If there’s one area that SBM needs to do better in, it’s regulating our own. To me, the license to practice medicine is a privilege, not a right. That I should even have to emphasize such a statement is bothersome to me, but all too often medical licenses, once obtained, seem to be treated as a right that can’t easily be taken away. That’s not to say that actually getting to the point of being licensed and board-certified isn’t difficult. It is. There’s the need to maintain excellent grades in college, after which there’s medical school and residency, both of which can be quite brutal. But once a physician is fully trained, board certified, and licensed, it seems that medical boards bend over backwards not to take away his license, seemingly even if he’s providing treatments so far outside the standard of care that they might as well be magic.

The case that provoked this complaint from me is one I’ve written about before, namely that of the Winkler County, TX family practitioner, Dr. Rolando Arafiles, Jr.. At the time, Dr. Arafiles was selling dubious supplements, hawking colloidal silver, promoting Morgellon’s disease quackery, and had anti-vaccine propaganda on his website. It turns out that — finally! — Dr. Arafiles is facing the Texas Medical Board for his substandard practice, as documented in a story on Medscape entitled Physician in Whistle-Blower Case Charged by Texas Medical Board:

The Texas Medical Board (TMB) has charged a family physician at the center of a nationally publicized whistle-blower case involving 2 nurses with poor medical judgment, nontherapeutic prescribing, failure to maintain adequate records, overbilling, witness intimidation, and other violations.

The charges follow a report that the 2 nurses — Anne Mitchell, RN, and Vickilyn Galle, RN — made anonymously to the TMB last year about patient care rendered by Rolando Arafiles, Jr, MD, at Winkler County Memorial Hospital in Kermit, Texas, where the 2 nurses and Dr. Arafiles worked.

After the TMB contacted him about the report, Dr. Arafiles asked the sheriff of Winkler County to investigate its source. The sheriff, the physician’s acknowledged friend and patient, traced the report back to Mitchell and Gale, who were then charged in a state court with misuse of official information, which is a third-degree felony.

The American Nurses Association at the time called the criminal prosecution “outrageous,” arguing that nurses were obligated to stand up for patient safety.

A local news report on the case can be found here:

A brief recap of the Winkler County nurses case

Readers might recall that Dr. Arafiles achieved notoriety when these two brave nurses reported their concerns about Dr. Arafiles’ substandard care to the Texas Medical Board. However, it should be noted that the failure to discipline Dr. Arafiles is not simply a problem of the TMB. Remember, prior to going to the TMB, Galle and Mitchell had taken their complaint through formal channels at the 25-bed rural hospital where they worked, Winkler County Memorial Hospital. Their complaints were in essence ignored. Moreover, it’s not as though these problems were subtle. They weren’t, and they became apparent immediately after Dr. Arafiles joined the medical staff of Winkler County Memorial Hospital, as I documented. More appallingly and all too often not mentioned or barely mentioned is that Winkler County Sheriff Robert Roberts, Jr. was not only just Dr. Arafiles friend and patient, but he had been in business with Dr. Arafiles selling supplements. In fact, during crossexamination, Dr. Arafiles even described how Sheriff Roberts had sold his nutritional supplement called “Zrii,” going so far as to hold meetings at the local Pizza Hut to recruit other sellers. No wonder when it came to chasing down these nurses, Sheriff Roberts transformed himself from Barney Fife to, as I put it, Jack Bauer on crack. At least he didn’t torture anyone — physically, that is. He certainly tortured Mitchell and Galle mentally and emotionally, destroying their careers in the process with his misuse of his power.

To bring this post back to the topic of SBM and how state medical boards too often fail to restrain or discipline physicians who not only don’t practice SBM but practice medicine far enough outside the realm of SBM to be dangerous, let’s take a look in light of what we know about Dr. Arafiles the charges pending against him before the TMB:

In a complaint filed last month with a state administrative court, the TMB charged Dr. Arafiles with 9 instances of substandard care. In 1 case, the TMB stated, he sutured part of the rubber from suture-kit scissors to a patient’s torn and broken thumb (in his trial testimony, Dr. Arafiles said he was attempting to stabilize the fracture). And when another patient was admitted to the hospital for an abscess caused by methicillin-resistant Staphylococcus aureus, Dr. Arafiles rubbed an olive oil solution — not on the hospital’s formulary and not approved by the US Food and Drug Administration for this purpose — on the abscess, according to the TMB. The nurses had reported to the TMB that Dr. Arafiles promoted the use of herbal medicines.

I’m going to be honest right here. This doesn’t sound very bad at all compared to Arafiles’ promotion of Morgellons disease and anti-vaccine quackery, as well as his hawking of colloidal silver to treat H1N1. As a surgeon, I may frown on suturing part of the rubber from a suture kit scissors to a patient’s thumb as a not particularly effective way to stabilize anything but, given that disposable suture sets are sterile, it probably didn’t do any harm. I doubt I’d recommend yanking Arafiles’ license over this alone, although I’d probably recommend that Arafiles have a bit of education over the proper way to suture. As for rubbing olive oil on an MRSA abscess, it’s true that this is inadequate treatment in and of itself for an abscess. Although some abscesses can be treated with antibiotics alone, the vast majority of abscesses require drainage of the pus in order to heal. For skin abcesses, that usually ends up meaning “lancing” the boil, cleaning out the pus, and packing the wound daily. If the only thing Dr. Arafiles was doing were rubbing olive oil on the abscess, then there’s no doubt that would be substandard care. If, on the other hand, he were also treating it with vancomycin and/or “lancing” the boil, then, although the olive oil didn’t add anything, it’s probably didn’t do any harm or interfere with the treatment of the abscess, either. I e-mailed a representative of the Texas Nurses Association a request for the full complaint, but did not receive it in time for this post; perhaps I’ll post an addendum when I have the full text of the complaint.

A strange set of charges

Upon perusing the list of charges brought by the TMB against Dr. Arafiles, I find it odd that the TMB focuses on these things, rather than Dr. Arafiles’ egegrious offenses against SBM that are easily found on the Internet. More serious are the charges in this list:

The TMB also alleged that Dr. Arafiles:

• diagnosed hypothyroidism in 1 patient without any testing and diagnosed the same disorder in a second patient despite normal thyroid function tests;
• prescribed hormone replacement therapy (HRT) for a woman whose lab work showed testosterone, estradiol, and progesterone levels within the normal range — HRT was contraindicated for the woman because of a history of deep vein thrombosis, which reoccurred after HRT was initiated;
• performed and billed for unnecessary genitourinary exams;
• failed to adequately document the care he provided; and
• engaged in witness intimidation regarding the 2 whistle-blowing nurses.

The first two complaints are common in the “alt-med” world. Suzanne Somers, for example, appears to believe that virtually every woman needs supplementation with “bioidentical” estrogens, while diagnosing thyroid disorders based on dubious tests or not tests at all also appears to be a cottage industry. There’s a lot of quackery in both areas, that’s for sure. More disturbing is Dr. Arafiles’ performing unnecessary genitourinary examinations. Usually, when a state medical board examines such a complaints, it’s almost always a male physician doing unnecessary pelvic examinations. Failure to adequately document care is a bit of a catch-all; I daresay that virtually every physician could be accused of that for one or more patients if someone looked at his or her patient charts.

All of these are bad. Indeed the charge of witness intimidation should go far beyond mere action against his license by the TMB. This is a felony. Given that the Winkler County prosecutor, Sheriff, and Dr. Arafiles himself are clearly part of a good ol’ boy network that closed ranks against these “uppity” nurses, the Texas state attorney general should investigate and press charges against not just Dr. Arafiles, but against Sheriff Roberts as well. What I can’t help but note is the selectivity of the choice of the TMB, given that many of Dr. Arafiles’s other offenses against the standard of care and medical ethics were right there on his website, Health2Fit, which Dr. Arafiles has eliminated since February and is not archived anywhere that I can find. I knew I should have downloaded the entire website when I was writing about this last in February. Fortunately, I kept several pages because I knew Arafiles’ website would disappear down the memory hole soon, including its links to other Morgellons sites and the section where it sells “Alka Vita Silver” to cure various ailments, including H1N1. Here are some screen shots from my archive of Dr. Arafiles’ Health2Fit website. (Note that Dr. Arafiles claims ownership of Health2Fit on his LinkedIn page.)

Here’s where Health2Fit sells a “water alkalinizer” for $1,495 (click on images to embiggen):

And here are some of the claims Dr. Arafiles made for his alkalinizer:

Here’s Dr. Arafiles’ quack Miranda warning, which is quite extensive:

Finally, here’s the page where Dr. Arafiles sells colloidal silver and claims that it is efficacious against H1N1:

There are other examples, such as Dr. Arafiles taking a homeopathy course taught by Sherri Nakken and belonging to a group of physicians who prescribe intravenous hydrogen peroxide and bioluminescence therapy (whatever that is), but I think I’ve made my point, which is that Dr. Arafiles appears to have committed far more serious offenses against the standard of care and SBM than what the TMB is charging him with. In fact, other than the charge of witness intimidation, the charges that the TMB is bringing against Dr. Arafiles remind me more than anything else of the government’s prosecuting Al Capone for tax evasion. Of course, Al Capone went to jail and spent some time in Alcatraz, but it was rather unsatisfying that it was for a much lesser offense. Worse, there’s no guarantee that Dr. Arafiles will even have his medical license revoked. As I pointed out before, state medical boards are often very loathe to strip a doctor of his medical license.

More than a case about a single doctor

As I’ve pointed out before, the Arafiles case is about far more than just Dr. Arafiles. It’s easy for physicians like myself, who have never practiced in rural areas with few physicians but rather always in large cities or heavily populated suburban areas, to come to think that this is the way that medicine is practiced everywhere. I know I’d never be able to get away with what Dr. Arafiles got away with for as long as he got away with it. I can be easily replaced. Physicians like Dr. Arafiles cannot, and don’t think that they don’t know it. Add to that the problem that most state medical boards are understaffed, underfunded, and enforce regulations that are insufficient to deal with all the issues with which they are charged, and it’s not surprising that it takes truly egregious offenses to get their attention. Does anyone think that Dr. Arafiles would be likely to be facing the TMB this way now if he hadn’t been the focus of an internationally reported case and been caught using his crony the Sheriff to find out who had reported him and make sure they were punished. True, Galle never went to trial and Mitchell was acquitted by the jury in less than an hour, but neither of them have found work since then. Awards for integrity and bravery, as deserved as they are, don’t change that, nor does a $15,850 fine against the hospital.

Unfortunately, because most states devote too few resources to their state medical boards and the enforcement of laws and regulations governing physician conduct, most state medical boards are very reluctant to go after physicians practicing “alternative” medicine as being below the standard of care because doing so involves a value judgement regarding medical science and evidence. Also, most state medical boards are made up of physicians, and if there’s one thing about physicians it’s that we all realize that all of us, even the best among us, are one mistake away from a potentially bankrupting malpractice suit. Consequently, physicians tend to be loathe to be too critical of other physicians, much less sit in judgment of their decisions or the science (or lack thereof) by which they justify their decisions. It’s far easier to go after physicians who are impaired due to drugs or alcohol, who commit obvious crimes, or who sexually abuse patients. These are offenses that virtually everyone understands and condemns in a physician (or anyone else, for that matter). No need to adjudicate on scientific evidence or clinical trials. As Kimball Atwood put it:

When a physician is accused of DUI, “substance abuse,” being too loose with narcotic prescriptions, throwing scalpels in the OR, or diddling patients, the response of a state medical board tends to be swift and definitive. Shoot first, ask questions later. After all, the first responsibility of the board is to the public’s safety, not to preserving the physician’s livelihood. One might therefore expect that a physician accused of using dangerous, substandard treatments would face a similar predicament. As you’ve undoubtedly guessed, such is not the case.

Indeed, it is not, and Kimball proceeded to provide four examples.

Then there’s the issue of licensure itself. As we have pointed out numerous times right here on SBM, there is a concerted effort by proponents of unscientific medical modalities, such as naturopathy, to obtain licensure, or at least to make the law more friendly to them. Perhaps the most spectacular example of the latter tactic is that of Dr. Rashid Buttar. Regular readers will recall that Dr. Buttar has been under investigation by the North Carolina Board of Medical Examiners for quite some time for his tendency to diagnose cancer patients and children with autism as having “heavy metal toxicity” and then to treat them all with some variant of his chelation therapy, plus lots of supplements and other woo, of course. He even referred to the board as a “rabid dog” at one point, something that most people accused of breaking the law would probably be well-advised not to do before their case reaches trial.

Dr. Buttar, however, apparently had reason to be confident. During the last two or three years, during which time the NCBME was investigating him, Dr. Buttar led a charge by the North Carolina Integrative Medical Society to get legislators to change state law to make it friendlier to practitioners of alternative medicine. He succeeded. As a result, the board didn’t think it could succeed in stripping Dr. Buttar of his medical license or even banning him from treating cancer patients and children:

Dr. Rashid Buttar, whose alternative medical practice in Huntersville has been under scrutiny by the N.C. Medical Board for a decade, has accepted a reprimand from the licensing agency.

But Buttar, who was facing potential restrictions to his license, instead can continue offering unconventional treatments as long as he asks patients to sign a form acknowledging his practice is outside the mainstream.

The reason was clear:

Mansfield, the board’s attorney, said a change in state law, which took effect in October, was partly the reason. The law, one of those that Buttar had pushed for, 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 than prevailing treatments.

It’s an astounding double standard. All Dr. Buttar has to do is to have patients sign in essence a waiver, an acknowledgment that what he is doing does not meet the standard of care and is not validated by science, and he can do whatever he wants, even treat autistic children with urine therapy to “boost their immune systems.” He doesn’t have to prove a thing; if the board wants to go after him it has to prove that “non-traditional” treatments are ineffective or more harmful because North Carolina law now deceptively conflates experimental treatments (which don’t get to the point of being experimental without a lot of preclinical evidence) with “non-traditional” treatments (which often have little or no good scientific evidence for their efficacy). In other words, Dr. Buttar and his ilk don’t have to demonstrate that their woo works; authorities have to demonstrate that it doesn’t. It’s a perfect reversal of what the standard of evidence should be in medicine, and means that North Carolina is now as quackery-friendly a state as there is. Meanwhile, doctors with ethics who treat patients according to science-based guidelines have to justify their treatment decisions. Nor is this a problem that is confined to the United States. Just consider how long it took the U.K. to finally strip Andrew Wakefield of his license to practice medicine.

If we as physicians are ever going to counter this problem, we’re going to have to accept that the problem exists and then do two things. First, we have to restrain our longstanding impulse to circle the wagons and protect a member of the tribe at all costs, even when we know that member has stepped far afield from the land of science-based medicine. Second, we have to lose some of our reluctance, particularly at the state medical board level, to pass judgment on non-scientific treatments like homeopathy, naturopathy, or others. Being a shruggie is no longer acceptable. Our system of regulating physicians and protecting the public from quackery is clearly broken. Will we rise to the challenge to fix it, or will we allow promoters of unscientific medicine to infiltrate and destroy it?

In the meantime, here’s hoping that Mitchell and Galle prevail in their civil suit against Dr. Arafiles, Sheriff Roberts, Winkler County, and Winkler County Memorial Hospital, among others. A message needs to be sent that complaints against physicians practicing below the standard of care should not endanger the livelihood of the whistleblower.

ADDENDUM: A copy of the formal complaint against Dr. Arafiles can be found here.