Physician executives can prepare for the possibility that a member of their medical staff may be spreading inaccurate medical information.
That’s the word from physician leaders, attorneys, and medical ethicists who are tracking the topic. Chief medical officers play an important role in addressing the spread of inaccurate medical information, but they are not on their own, says Suzanne White, MD, MBA, a member of the board of directors of the American Board of Emergency Medicine (ABEM).
Medical specialty boards require board-certified physicians to comply with their codes of professionalism. “CMOs should understand that we are here to support the public, and we’re certainly here to support them,” says White, a former chief medical officer at Detroit Medical Center and Bayfront Health in Florida.
Attorneys can help physician executives understand how physicians who promulgate medical misinformation might jeopardize their health systems by ensnaring them in litigation or sullying their reputation. Richard Saver, JD, a professor of law at the University of North Carolina (UNC) School of Law and a professor of social medicine at the UNC School of Medicine, says, “I think that’s the larger issue: the reputational hit to institutions when physicians affiliated with them become associated with misinformation messages.”
Medical ethicists can help hospital leaders develop policies that articulate the professional expectations for members of their medical staff. “Obviously, physicians have judgment in their medical care of their patients, but health systems have an obligation to protect their patients from measures that are known to be harmful or ineffective,” says Arthur R. Derse, MD, JD, director of the Center for Bioethics and Medical Humanities and professor of bioethics and emergency medicine at the Medical College of Wisconsin. “That engages the ethical principles of not harming and acting for the benefit of patients.”
WHY IT MATTERS
Inaccurate information spread by physicians, whether intentional or unintentional, is not a new phenomenon, but it emerged as a major issue during the COVID-19 pandemic in part because social media platforms provide a megaphone. Indeed, when the Federation of State Medical Boards (FSMB) surveyed its members in 2021, two-thirds of the 58 respondents reported an increase in complaints about licensed physicians disseminating false or misleading information during the pandemic.
“It really has risen to a level, thanks to social media, that most state medical boards and most medical staffs never had to consider before,” Derse says.
Arthur Caplan, PhD, director of the Division of Medical Ethics at NYU Grossman School of Medicine, predicts more controversy about medical misinformation in the foreseeable future.
In February, Robert Kennedy Jr., secretary of the U.S. Department of Health and Human Services, said the Make America Healthy Again commission will investigate the childhood vaccination schedule used in the United States. “So there will be more swirling opinion about misinformation being spread and then more people trying to defend what they are doing as not misinformation, but as issues that are back up for legitimate debate,” Caplan says.
Caplan thinks what constitutes legitimate debate may become its own point of contention. Specifically, he believes health systems should not participate in a randomized clinical trial to study the safety and effectiveness of a vaccine if earlier research has established that it is safe and effective. “You can’t take the kids’ vaccines away or change the schedule, saying, ‘Well, we’re not sure,’ if there’s a mountain of evidence that says we are sure,” he says. “That is withholding a proven benefit when, even though there may be dissent, the overwhelming evidence has to be respected.”
The FSMB also predicts that the misinformation problem will not fade away. Derse served as a subject matter expert on the FSMB Ethics and Professional Committee that issued a report, “Professional Expectations Regarding Medical Misinformation and Disinformation,” in April 2022. The report posits: “...in an age where misinformation can be widely spread online in an instant to a vast number of recipients, boards can expect to receive complaints about misinformation and disinformation with increasing frequency.”
The recent track record for physicians disseminating inaccurate information has been noteworthy. Four physicians were among the “Disinformation Dozen,” a list of 12 individuals responsible for a majority of the anti-vaccine content on social media platforms during two months in 2021. The Center for Countering Digital Hate, which compiled the list, called on social media platforms to remove their accounts, which violated the platforms’ policies to prevent the spread of vaccine misinformation. Instead, Facebook and X, formerly Twitter, have discontinued using independent fact-checkers.
Between January 1, 2021, and May 1, 2022, there have been 52 physicians in 28 medical specialties who communicated misinformation about COVID-19, according to an analysis conducted by Sarah Goff, MD, PhD, chair of the Department of Health Promotion and Policy at the University of Massachusetts-Amherst, and published in JAMA Network Open.(1) Misinformation was defined as “assertions unsupported by or contradicting U.S. Centers for Disease Control and Prevention (CDC) guidance on COVID-19 prevention and treatment or contradicting the existing state of scientific evidence for any topics not covered by the CDC.”
Most of those physicians posted inaccurate information on multiple platforms. Together, they had more than 20 million followers. Major themes included disputing vaccine safety and effectiveness, promoting unproven medical treatment, and disputing the effectiveness of masks.
In a 2023 article in the AMA Journal of Ethics, Alison J. Whelan, MD, chief academic officer for the Association of American Medical Colleges, identified five physicians who promulgated medical misinformation in their capacities as government employees, advisors, or members of the U.S. Congress.(2)
MISINFORMATION VERSUS DISINFORMATION
In their actions, physicians are responsible for following the standard of care guidelines set by professional medical societies, Caplan says. “The duty of the doctor is not to follow first and foremost their belief or their conscience,” he says. “The duty is to do what’s best for your patient, follow your patient’s values, and then try to practice according to agreed-upon standards of care.”
But what a physician can say or write in regard to medical information is inherently a delicate balancing act, Saver cautions.
“It’s a very tricky issue for law and medical ethics and certainly for chief medical officers,” he says. “We have historical examples where there have been naysayer physicians who have rightly questioned what was then an orthodox medical view. How do we ensure that there is not an overcorrection and over-deterrence that chills physicians who may want to raise legitimate questions about the medical status quo?”
According to the American Medical Association, the terms “misinformation” and “disinformation” should not be used interchangeably because they mean different things. In a 2021 report of the AMA Board of Trustees around its policy, “Addressing Public Health Disinformation Disseminated by Health Professionals,” the board clarifies that “Misinformation is spread unwittingly, whereas disinformation is intentionally disseminated to confuse, deceive, or otherwise manipulate …”(3)
That said, defining what constitutes inaccurate medical information — regardless of the intent of the purveyor — is not easy, Saver says. He points to two leading definitions in academic literature. One definition — “information that is contrary to current medical consensus” — raises a lot of questions.
“What does ‘consensus’ mean?” he says. “Do we look to peer-reviewed literature? Do we look to anecdotal views of physicians in the community? How many physicians have to believe something for it to be a consensus? Do we take less rigorous evidence than randomized controlled trials that result in published medical studies? It’s particularly difficult with newly emerging diseases like COVID-19, when you initially are not going to have gold-standard evidence to begin with.”
The other leading definition is “information contrary to the best evidence available,” which removes the idea of consensus. Saver sees problems with that definition as well.
“What is ‘best evidence’ in the absence of randomized controlled trials or published peer-reviewed literature?” he says. “There may be situations in which physicians are espousing a view that may be theoretically plausible and strong even though there is not much evidence backing it up.”
HOW TO BE PROACTIVE
Saver encourages CMOs to consider the possibility of a “soft power” opportunity to prevent members of their medical staff from wading into disinformation territory. If physicians who do not share the consensus view on a medical topic feel comfortable discussing their perspective with their colleagues, they may be less inclined to seek attention from the broader public.
“My own anecdotal sense is that some of these folks start with views that are a little unorthodox, they get roundly criticized, they get aggrieved, they find a following on social media, they get approval, and it kind of snowballs,” he says. “Thinking about this from a supervisory capacity, is there a way to give them an outlet so they feel that they are being heard without spouting off on social media?”
Other advice for physician leaders:
Review and, if necessary, amend medical staff bylaw policies to give physicians clear guidance regarding medical staff communication standards and misinformation Derse explains that bioethicists can help leaders consider the principles at issue and help develop the policy. Saver adds, “The more that you can have the bylaws express guidance about what we are expecting of our medical staff members, the better.” Sources of guidance include:
“Addressing Public Health Disinformation Disseminated by Health Professionals,” published by the American Medical Association.(4)
“Ethics and Academic Discourse, Scientific Integrity, Uncertainty, and Disinformation in Medicine: An American College of Physicians Position Paper.”(5)
Professional Expectations Regarding Medical Misinformation and Disinformation, published by the Federation of State Medical Boards.(6)
Make sure all medical staff members are aware of your organization’s expectations. “You need to onboard people with very clear policies about what they can and can’t do on social media, what it means to ‘be on your own time,’ and what it means to use the institution’s name,” Caplan says. “It ought to be clear when a physician cannot use organizational titles.”
Remind physicians to be mindful of the rules surrounding doctor-patient relationships. Caplan suggests: “Tell them ‘In this day and age, there are all kinds of issues that come up where you may have issues of conscience, and there may be issues that come up where you may feel like it’s necessary to violate the law. If you get in that kind of situation, you should speak immediately to the hospital attorney to be advised about your particular situation.’ ”
If a member of the medical staff is suspected or accused of spreading misinformation, don’t ignore it. Caplan recommends a face-to-face discussion — not email, Zoom, or anything else — so the CMO can hear what is being said and assess the person’s candor.
However, the CMO may not be the best person to determine if the information at issue constitutes misinformation. “They may think they know misinformation when they see it professionally, but specialty boards and state boards are larger groups with access to wider medical expertise,” Derse says.
Access the specialty organization in which the physician is board-certified to see what its standards and recommendations are. Then contact the state’s medical board for its standards and recommendations. The state board can be an appropriate place to lodge a formal complaint about misinformation.
If it seems likely that the physician has spread misinformation, the CMO should confer with the organization’s legal counsel to discuss what actions might be appropriate.
THE ROLE OF MEDICAL BOARDS
State medical boards can discipline physicians for spreading medical misinformation, but they have rarely done so, according to Saver’s research.(7) His analysis of medical board disciplinary actions in the five states with the biggest populations during the early COVID-19 years found that spreading misinformation to the community accounted for 0.1% of all identified offenses.
Saver believes one reason may be medical boards, which are governmental entities, are constrained under constitutional law from impinging on physicians’ free speech rights, even if they are making false communications. By contrast, medical specialty boards are private organizations that do not face the same constraint.
“I think they have an important role to play because physicians will respond to their pressure,” he says. “Not only is certification prestigious, but [also] some payer contracts require that you maintain your certification.”
Members of the American Board of Medical Specialties can revoke a physician’s certification for breaching professional norms, including knowingly and repeatedly disseminating misinformation.
Professionalism has always been a principle of all medical specialty boards, White says, but concerns about medical misinformation prompted some boards to fine-tune their documents. The ABEM, for example, developed a code of professionalism as well as a statement on physicians who are providing misleading information.
“Of course we believe that board-certified emergency physicians have every right to express their opinions on medical issues, but to make public statements that are directly contrary to prevailing medical evidence is where we believe there could be unprofessionalism involved,” says White, chair of the ABEM Health Care Administration, Leadership, and Management Advisory Committee.
When the ABEM becomes aware that a board-certified emergency physician is providing information that is contrary to the health of patients or could hurt public safety, it conducts a multi-level, due process review. ABEM staff members collect information associated with the issue and provide this information to the board of directors for review. An appeal process is available for physicians who are subject to possible loss of their board certification.
“Our role is to make sure that the public has the best medical care and is protected from any consequences that could affect the quality of their care or the safety of the public based on misinformation,” White says.
REFERENCES
Sule S, DaCosta MC, DeCou E, Gilson C, Wallace K, Goff SL. Communication of COVID-19 Misinformation on Social Media by Physicians in the US. JAMA Netw Open. 2023;6(8):e2328928. https://doi.org/10.1001/jamanetworkopen.2023.28928
Whelan AM. How Should State Licensing and Credentialing Boards Respond When Government Clinicians Spread False or Misleading Health Information? AMA J Ethics. 2023 Mar 1;25(3):E210-218. https://doi.org/10.1001/amajethics.2023.210
American Medical Association Board of Trustees. Addressing Public Health Disinformation, Report 15-A-22. www.ama-assn.org/system/files/a22-bot15.pdf .
American Medical Association, Report 15 of The Board of Trustees (A-22) Addressing Public Health Disinformation. https://www.ama-assn.org/system/files/a22-bot15.pdf .
Sulmasy LS, Burnett JR, Carney JK, DeCamp M. Ethics and Academic Discourse, Scientific Integrity, Uncertainty, and Disinformation in Medicine: An American College of Physicians Position Paper. Annals of Internal Medicine. 2024;177(9):1244–1250. https://doi.org/10.7326/M24-0648
FSMB Ethics and Professionalism Committee. Professional Expectations Regarding Medical Misinformation and Disinformation. Federation of State Medical Boards. April 2022. https://www.fsmb.org/siteassets/advocacy/policies/ethics-committee-report-misinformation-april-2022-final.pdf .
Saver RS. Medical Board Discipline of Physicians for Spreading Medical Misinformation. JAMA Netw Open. 2024;7(11):e2443893. https://doi.org/10.1001/jamanetworkopen.2024.43893