"QUACK" says the Quack, the Board says "NEIGH" - it's quiet now, what do you say?

with apologies to Sandra Boynton

On 22 August 2012, the Maryland State Board of Physicians revoked Mark R. Geier's license to practise Medicine (dare I say "finally"?). This follows almost a year of legal proceedings (covered very well by Todd W. at Harpocrates Speaks, here, and here and by Kathleen Seidel at Neurodiversity.com, here and here) - visually:

On September 15, 2011, the Board charged Mark R. Geier, M.D., with numerous violations of the Medical Practice Act, including: (1) unprofessional conduct in the practice of medicine; (2) willfully making or filing a false report or record in the practice of medicine; (3) willfully failing to file or record any medical report as required under law; (4) practicing medicine with an unauthorized person or aiding an unauthorized person in the practice of medicine; (5) grossly overutilizing health care services; (6) failing to meet appropriate standards for the provision of quality medical care; and (7) failing to keep adequate medical records, under Md. Health Occ. Code Ann. § 14-404(a) (3) (ii), (11), (12), (18), (19), (22), (40), respectively. 

A five-day evidentiary hearing was held before an Administrative Law Judge ("ALJ") ofthe Office of Administrative Hearings in December of 2011. On March 13, 2012, the ALJ issued a Proposed Decision finding that Dr. Geier had violated numerous provisions of the Medical Practice Act and recommending that his license be revoked. Exceptions and responses were filed by both parties. An oral exceptions hearing was held before the full Board on May 23, 2012. This Final Decision and Order is the Board's final administrative decision in this case.

Carole J. Catalfo, the Executive Director of the Maryland State Board of Physicians has had it. Her ruling leaves nothing open to interpretations - she finds (footnotes removed):

(1) Dr. Geier failed to meet basic medical standards for evaluating patients and conducting medical examinations and keeping adequate records of treatments and diagnoses. He failed to conduct an adequate initial evaluation of any of these patients and failed to make an adequate record of an examination for any of these patients. He began treatment often without sufficient information about the patients' physical condition. In many cases, [Dr. Geier] had no information at all about the Patients' physical condition.,

This is consistent with the details that came out in the case of Dr Geier's son David Geier practising Medicine without a license (Justthevax passim). She further finds:

(2) Dr. Geier treated patients with Lupron, a medication that is not approved by the FDA in the absence of precocious puberty. He did not, however, perform an adequate examination to determine whether these patients had precocious puberty, or the cause of these patients' symptoms. ../.
(3) Based on his theory that Lupron therapy is appropriate in certain situations in which its administration is not approved by the FDA or the American Academy of Pediatrics, Dr. Geier purported to treat patients who met his profile with Lupron. With the exception of Patient E, however, none of these patients met even Dr. Geier's profile for Lupron therapy.

This abhorrent practise to "diagnose" any child with "precocious puberty" irrespective of age and physical evidence to be able to prescribe Lupron, a strong hormone modulator, which essentially equals chemical castration is part of Team Geier's proprietary theory. They postulate (I paraphrase - see père et fils Geier here) that excessive testosterone binds mercury from vaccines in the body/brain, and that the administration of Lupron will release the mercury which can than be chelated. That is complete gobbledygook of course, but unfortunately, far too many parents believed them (read Kathleen Seidel's outstanding series on "The Lupron Protocol") - the Geiers claimed to have treated more than fifty children already in 2006. Consequently, following Lupron prescription:

(4) Dr. Geier prescribed chelation therapy to patients who failed to display the need for chelation. He began this therapy without documenting a reason for the treatment and without adequate documented informed consent. He violated the standard of quality care by so doing. He also violated the standard of quality care by prescribing for patients the drug DMPS, a drug not approved for any use in the United States.

(5) Dr. Geier provided a consent form to the parent of Patient I that named an FDAapproved drug and which falsely stated that it was to be used in the chelation treatment when another drug, DMPS, which was not FDA-approved, was to be used (and in fact was used) in the chelation treatment. 

It gets worse:

(6) After prescribing these treatments without an adequate previous medical examination and without adequate informed consent, Dr. Geier then failed to adequately monitor whether these treatments were working.

"Experimental" treatments on human patients will have to undergo review by an institutional review board, which is supposed to advise and control the physicians. The Geiers' review board was made up of family and friends:

(7) Dr. Geier provided drug therapy to Patient I according to a protocol not approved by the FDA after telling the parent that his protocol was approved by an Institutional Review Board, when in fact the Institutional Review Board consisted entirely of persons affiliated with his practice and did not meet the requirements of federal or state law.

The court further finds that Dr Geier had parents sign an "informed consent" form that named the wrong drug (FDA licensed) to be applied, while an unlicensed drug ended up being used on their children (8). He inflated his credentials, claiming an American Board of Medical Specialties certification he did not have (9). The Board also finds that the record keeping of Dr. Geier was too poor to even be suitable for assessing patient progress. Nevertheless, he made decisions to continue or alter medication (10). Dr. Geier falsely made a diagnosis of precocious puberty in patients who did not have this condition and he did not perform the necessary medical examinations to be able to make this diagnosis (11). 

It appears that Mark Geier had objections to Dr. Grossman as an expert witness, saying that she was not a "true peer". Given her impressive list of qualifications, I would almost tend to agree with that notion - the court states:

Dr. Grossman is board certified in pediatrics and developmental-behavioral pediatrics and has been an Associate Professor of Pediatrics, the Director of the Behavioral and Developmental Pediatrics Fellowship Program at the University of Maryland School of Medicine and the head of the Division of Behavioral and Developmental Pediatrics at that institution. She has also held many other positions of great responsibility in her 35-year career in pediatrics. She testified knowledgeably about the standard of care applicable to pediatric patients in general and to these patients in particular. The Board is satisfied that she was appropriately admitted as an expert in this case.

I felt like hugging Carole Catalfo for the following statement:

The fact that she may not have been familiar with the details of some of Dr. Geier's idiosyncratic theories, theories that appear to be supported in large part by literature that he or his son created and which have been rejected to some extent by the Institutes of Medicine of the National Academy of Science, does not detract from the weight of her testimony about the quality of the actual medical treatment provided to these patients, in the Board's opinion.

True that! The deconstruction of Mark Geier continues, as Dr Catalfo observes:

Dr. Geier, however, is not a "trained clinician." He completed only a one-year residency in obstetrics and gynecology, has no formal specialized training in the treatment of autism, and is not Board certified in any medical specialty.

The board also had few good words about the statements of Dr. Jerry Kartzinel (if the name rings a bell that is because you have seen him on this with Andy Wakefield):

The Board also notes that Dr. Kartzinel's testimony on the adequacy of Dr. Geier's physical examinations of these patients was particularly unpersuasive. ../..

He testified that a physical examination of the patients is highly overrated (Tr. 200) and that the physician "generally ... can bide by his eye" (Tr. 148-49) and just try to "get a gestalt," and that it is not even necessary for the physician to document that "gestalt" in the medical record. (Tr. 182) It is sufficient for the physician then to "step back and say, did I get a clinical response that everybody is thrilled with, or was it a swing and a miss," according to Dr. Kartzinel. (Tr. 155) In the Board's opinion, what Dr. Kartzinel describes as an acceptable medical examination and mode of treatment is not acceptable at all, and it is questionable as to whether this conduct can even be described as "medical."

Traurige Gestalt* is more like it. The hubris that those phrases reveal is not untypical amongst the "brave maverick doctors".

In their ruling, the State Medical Board do not speak to the allegation that Dr. Mark Geier let his unqualified son, David, practise Medicine. The Board state that this is being dealt with elsewhere (it has been) and that:

The Board will not make a decision in this case on this same factual issue based upon the less complete record made in this case. In light of the egregious violations of the standard of quality care and the deliberate unprofessional conduct set out in the numbered facts recited above, a decision as to whether Dr. Mark Geier also allowed Mr. David Geier to practice medicine without a license would have no effect on the sanction that the Board would impose on Dr. Mark Geier.

Read the Sanction in full, very slowly, word by word to understand that these proceedings dealt with a high number of unambiguous violations and there is really no room for a "misunderstanding" of what happened:

The ALJ commented that Dr. Geier abused the trust that these patients' families placed in him. "By dissembling, misrepresenting, failing to see his patients for months and years before treating them, applying a protocol-based treatment to children who do not fit the protocol, using non-FDA-approved drugs without fully informed consent, and for all of the other violations found and discussed in this Proposed Decision, he abused that trust. I agree with the State that these actions betray the relationship of a physician to a vulnerable child and his desperate parents."
The Board agrees.
The ALJ proposed that the Board revoke Dr. Geier's license. Dr. Geier has displayed in this case an almost total disregard of basic medical and ethical standards by treating patients without properly examining or diagnosing them, continuing treatment without properly evaluating its effectiveness, and providing "informed consent" forms that were misleading and in at least one case blatantly false. He provided treatments supposedly according to an investigational protocol, but the investigation was approved only by a sham Institutional Review Board, and he applied protocols to patients who did not fit his own profile. He provided treatment by a drug not approved for use in this country while informing parents that a different drug would be used. His actions toward his patients were not those of an honest and competent physician, nor do they appear to be those of an objective and ethical researcher. Dr. Geier made little use of those methodologies that distinguish the practice of medicine as a profession. At the same time, he profited greatly from the minimal efforts he made for these patients. In plain words, Dr. Geier exploited these patients under the guise of providing competent medical treatment. Such a use of a medical license is anathema to the Board. The Board has no hesitation in revoking his medical license.

Which they do:

What do I say? For the moment, I remain very quiet and listen to the weeeeeee sound that the Geiers' descent makes - they have been falling for a while and they have not hit rock bottom yet. It is likely that the repeated practising Medicine without a license and the number of other behaviours that led to this license revocation will have further consequences (like fines or even jail time). I also think that some insurance companies might want to have another look at the diagnosis and prescription practise of Dr Geier. Some parents (especially if they had to pay out of pocket) might want their money back.

Most of all though, as a parent, I am relieved that vulnerable children are safe from unlicensed drugs in uncontrolled treatment of undiagnosed conditions based on untrue hypotheses. My hope is that those who were treated with Lupron will not have sustained permanent damage and will find trained specialists to take care of their (hormonal and other) needs.

*sad figure

Hat tip to Stephen Barrett, MD

ETA: now also very nicely covered by Todd W. on Harpocrates Speaks