After writing about the failure of state medical boards to discipline physicians who practice quackery and an apparent notable exception in Tennessee just yesterday, my attention was brought back to California and the topic of SB 277, the law enacted last year that, as of July 1 this year, eliminated non-medical exemptions to school vaccine mandates. As anyone who’s read this blog for more than a year knows (or anyone who’s just paid attention to the political battle to pass SB 277 lsat year in the wake of the Disneyland measles outbreak), once the battle was over and antivaccine activists lost, their attention turned immediately to finding ways to get around the law. Unfortunately, the law provided a way.

There are now three states in the US that do not allow nonmedical exemptions to school vaccine mandates: Mississippi, California, and West Virginia. Not surprisingly, just as antivaccine parents have tried to falsely claim religious exemptions in states that only Each of them has different standards for documentation of what is required to qualify for a medical exemption that fall into two categories. The most strict is West Virginia, where requests for medical exemptions are reviewed by an Immunization Officer, who determines if they are appropriate “based upon the most recent guidance from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) with respect to medical contraindications or precautions for each vaccine.” In Mississippi and, now, in California, all that is required is a letter from a physician.

You might ask: So what’s the problem with just letting any old physician write a letter supporting a medical exemption to school vaccine mandates in California? It’s a system that seems to work very well in Mississippi. Here’s the problem: California is not Mississippi. One key difference is that California is has a lot more antivaccine parents; indeed, it is arguably the epicenter of antivaccine activism in the US, which is why the resistance to SB 277 was so loud and public. It’s also why I’ve said on more than one occasion that when the outbreaks occur they’ll start in California. Another key difference is that California is chock full of antivaccine and antivaccine-sympathetic pediatricians and family doctors who have seen a lucrative business opportunity selling medical exemptions to all of these antivaccine parents. Indeed, I speculated whether this would happen right around the time SB 277 passed.

So did others:

@gorskon @MyHealthyBabies @JayGordonMDFAAP No doubt some CA doctors will profit from this. I hear Bob just ordered a new Lamborghini. — Greg Hinson (@ackdoc) June 30, 2015

Dr. Bob, of course, is Dr. Bob Sears, the antivaccine-sympathetic pediatrician who’s’ most famous for a book full of bad advice on vaccines and, during the political battle over SB 277, prone to going full Godwin over the bill. Consistent with that, it didn’t take Dr. Bob very long at all to start giving seminars on how to get medical exemptions and avoid school vaccine mandates under SB 277. At the time, mere weeks after the passage of SB 277, Dr. Bob focused on non-evidence-based reasons for medical exemptions and ways to get around the law other than home schooling. For example, he suggested getting an Individualized Education Program (IEP) that specifies regular classroom time. IEPs are mandated by the Individuals with Disabilities Education Act (IDEA) for children with special needs. If a child receives special educations services, he must have an IEP that includes a description of how the child is doing, the child’s specific annual education goals, specific special education supports and services that the school will provide to help the child reach those goals, modifications and accommodations the school will provide to help the child make progress, and other information. To comply with federal law, SB 277 specifically stipulates that the law “does not prohibit a pupil who qualifies for an individualized education program, pursuant to federal law and Section 56026 of the Education Code, from accessing any special education and related services required by his or her individualized education program.” So Dr. Bob recommended that parents seek an IEP, even for “minimal speech delay or learning issue” when the child is 2 or 3 years old so that they have it later and will be “protected” from SB 277 for the entire child’s school career.

Less than three months ago, I learned that there was now basically a cottage industry of bogus medical exemptions, with physicians such as Dr. Tara Zandvliet, Dr. Kelly Sutton, and, of course, Dr. Bob Sears selling medical exemptions based on medical reasons not supported by science.

What I don’t talk about that much on this blog is how often people write to me about the issues I discuss on this blog. Sometimes it’s just abuse from people who don’t like my point of view on alternative medicine, vaccines, and science. Sometimes, it’s people asking for medical advice, which I really can’t give, except in general terms. Sometimes it’s people telling me their stories about encounters with quacks. Of these, reading stories of patients whose family members have chosen, for example, Gerson therapy instead of real medicine are the hardest to read and steel me to continue what I do. Sometimes people let me know about something that I might want to blog about. This was one of those times, as it was the story of a parent and Dr. Bob’s vaccine exemptions that demonstrates how bogus these exemptions are.

I won’t tell you whether this was a male or a female, and I’ve stripped all potentially identifiable information from the genuine letters generated by Dr. Bob’s office in support of medical exemptions for their children. I’m going to refer to this parent as “he” for convenience and based on the default to male pronouns in English. Basically, this story developed out of, unfortunately, divorce, where the person who wrote me is not the custodial parent. He describes himself as formerly antivaccine but now pro-vaccine, which, as described, caused a rift in the marriage to the point where his spouse left. This is, unfortunately, a story I’ve heard too many times. In any case, this person who wrote me wants the children vaccinated. His spouse, however, does not, and his spouse stymied him by getting a medical exemption from Dr. Sears. Basically, his spouse filled out an online history form, paid a fee of $180 per child, and Dr. Bob’s office spit out these two boilerplate exemption letters. Nothing about them has been altered, other than to white out the names, dates of birth, and the date of the letter. (I wouldn’t want Dr. Bob to be able to figure out who it was based on the reasons for exemption and the date issued. Let’s just say that it was within the last four months or so.) Here are the letters (click to embiggen):

Note the bogus reasons:

Family history of Autoimmune Disorders, Inflammatory Bowel Disease, Neurodevelopmental Disorders, Psychiatric Disorders.

His own current medical problems.

My reader described how he showed these letters to the children’s regular pediatrician, who was appalled. By e-mail (and, by the way, I’ve saved every e-mail), I urged him to report Dr. Bob for what, in my opinion, is highly unethical behavior and failure to meet the standard of care. After all, Dr. Bob never actually examined the patient and appears never to have verified even the medical history. Basically, he appears to have an online form that a parent can fill out and get a medical exemption for pretty much any condition. I was assured that a report to the Medical Board of California has been filed.

To be honest, given how many quacks practice in California, I’m not as optimistic as I’d like to be that anything will be done about Dr. Bob’s issuing boilerplate medical exemptions unless there are a lot of complaints. That’s the problem. The very parents who take advantage of such a “service” are the very parents least likely to complain to a state medical board about the physician providing the service. After all, such parents got what they want: an exemption from vaccinating their children. Because they are antivaccine and motivated enough to seek out such a service, they really don’t care how they got the exemption; all they care about is that they got it. Cases like this one, where one parent has become pro-vaccine and objects enough when the other parent uses a physician like Dr. Bob to obtain a medical exemption are almost certainly comparatively rare. No doubt Dr. Bob will get that new Lamborghini if he decides he wants it.

Still, I’m hopeful that publicizing this story, with the permission of my reader, will draw some attention to Dr. Bob. In the meantime, I referred my reader to people who can help find legal help if he doesn’t already have it. If ever there were a case that cried out for investigation by the Medical Board of California, this is it.