Doctor discipline—or "medical McCarthyism"?

Licensing boards say they're protecting patients from dangerous mavericks. The doctors say they're being persecuted for deviating from medical orthodoxy.

By Mark Crane
Senior Editor

Are physicians who treat patients they diagnose with chronic Lyme disease charlatans who need to be disciplined to protect the public? Or are they victims of "medical McCarthyism" instigated by managed care companies that just don't want to pay the bills?

That was the issue as a group of doctors and about 400 of their patients gathered on a Manhattan sidewalk recently. They were protesting medical board investigations of physicians who use long-term antibiotic therapy to treat Lyme disease.

"It's almost certain that if a physician treats a significant number of patients with Lyme for an extended period, he'll be investigated by health plans and licensing authorities," says Michael Schoppmann, an attorney based in Bridgewater, NJ, who has represented more than 40 doctors in board hearings in the Northeast. "A number of physicians have lost their licenses, because boards are punishing those who dissent from the prevailing view about how to treat the disease. This has had a chilling effect on the willingness of physicians to help patients."

Many health plans don't recognize the diagnosis of chronic Lyme disease and balk at paying for long-term antibiotic therapy. They argue that such treatment is dangerous and that some physicians appear to have a financial interest in the regimen.

Schoppmann acknowledges that the treatment of Lyme disease in the past has been replete with fraud, with home infusion companies and physicians engaging in phony billings. But he argues that honest physicians are being tarred with the same brush of suspicion. "There is a medical controversy when we get into the ongoing, recurrent symptoms of Lyme, and many physicians are being persecuted because they believe in the concept of chronic Lyme status.

"Some physicians favor long-term therapy, and some don't. But this is a debate that should be taking place within medicine: in journal articles, conferences, and clinical trials. Licensing boards have no business picking sides and punishing a legitimate but minority point of view."

Most of the impetus for actions against doctors' licenses have come from managed care companies, Schoppmann says. "Not one of the cases I've handled has involved a complaint by a patient," he maintains. "The complaints are instigated by health plans. The licensing boards act like the attack dogs for the insurance industry. They rely too much on academic infectious disease experts and ignore the opinions of primary care physicians who have extensive experience.

"The treatment of Lyme disease and its financial implications are one of the insurance industry's worst nightmares," he continues. "No one dies from Lyme disease, no one is cured, and many patients require years of expensive treatment."

Several patients of a New York physician who's been brought up on charges before the state Office of Professional Medical Conduct attended the rally. They complained that their medical files had been used by the state without their knowledge, and said that the doctor being charged had brought them back to health or had improved their conditions. The physician, internist Joseph J. Burrascano Jr. of East Hampton, has been accused of failing to make a proper diagnosis and failing to follow up adequately with his patients.

"To have taken my files and put together any case against Dr. Burrascano is a kind of medical McCarthyism," a 77-year-old patient told The New York Times. "He slowly brought me along, with detailed explanations of what he was planning to do, trying different treatments, different kinds and dosages of antibiotics, trying physical therapy—until I finally returned to my old self."

Hearings regarding Burrascano, who has treated more than 7,000 Lyme patients from around the world over the past 15 years, are expected to take several months, attorneys predict. "Under state law, we cannot comment on the specific allegations against this physician while the matter is pending," says Kristine Smith, spokesperson for the New York State Department of Health.

Medical boards and health plans strongly disagree with the accusation that they're penalizing innovators. "There's a wealth of literature from major medical centers showing that many patients are being mistreated by long-term antibiotic therapy," says internist Charles M. Cutler, chief medical officer of the American Association of Health Plans.

"Many patients aren't being appropriately diagnosed. When they are sent to medical centers with broad experience, it turns out they don't meet the criteria for Lyme disease. Health plans have a responsibility to see that patients receive appropriate care. When something is amiss, plans have filed complaints with medical boards, and we make no apologies for that."

Indeed, plans could face penalties of their own if they are aware of potential misconduct and fail to report it, notes Kristine Smith.

"We have no position on the efficacy of long-term therapy," she says. "We are required to review all complaints of misconduct, no matter where they originate. If there's any evidence, we follow up on a case-by-case basis. The issue isn't the type of treatment per se, but whether that treatment meets the accepted standard of care as determined by a rigorous peer review process."

Smith mentions another New York physician whose license was revoked over his treatment of Lyme patients. "The issue wasn't the modality of treatment, but whether the overall treatment met the basic standard of care," she says. "We found it didn't. Some very basic medical practices weren't followed. That physician is appealing the ruling."

Although attorney Schoppmann and the demonstrators claim that investigations of physicians who treat Lyme disease are a national problem, health officials disagree. "The number of these controversial cases around the country is relatively small," says James R. Winn, an FP and executive vice president of the Federation of State Medical Boards, based in Euless, TX.

"What often happens in these situations is that advocacy groups for some unconventional therapy argue that the investigative focus is about the therapy itself," says Winn. "But when a medical board looks at a case, it focuses on the individual care that's rendered. There's a full peer review process at every board I'm aware of."

While the number of cases may be few, Winn says the debate over how physicians treat patients with Lyme disease is important. "There are severe complications with long-term antibiotic therapy," he says. "If a doctor is going to prescribe it, he'd better be damn sure the patient really has the disease."

 

Mark Crane. Doctor discipline--or "medical McCarthyism"?. Medical Economics 2001;6:51.