Alternative Medicine is Kicking Our Ass

 

While doing research for a different post, I recently stumbled across a website unlike the majority of histrionic thyroid sites on the internet.  This one has a crisp look with a clean user interface – nary an exclamation point nor an all-caps sentence to be found.  The site name* connotes authority and mastery of thyroidology, and it implies backing by a widely-respected organization.  The authors purport to synthesize all the medical journal evidence your doctor never read because – naturally – your doctor hasn’t learned anything new since medical school (yes, they make this claim, and they even cite evidence to back it up).  To any layperson, the articles on this site will almost certainly be regarded as well-written and convincing, especially since many of the assertions include references, with a prodigious bibliography at the end of each article.

After an hour or two of combing through the information on the site, I felt…unsettled.  For your reference, that is not my typical reaction to sites that promote alternative medicine.  Laughter, frustration, anger, incredulity – all pretty common.  But “unsettled?”  That’s a new one for me, so I decided to further explore what caused this emotion.

Facts, Alternative Facts, and their Interpretations

I believe it boils down to the fact that the aforementioned website consists of artfully crafted posts that cleverly weave together accurate scientific facts with inaccurate interpretations of those facts.  The articles include just enough complexity when describing the pathophysiology of hypothyroidism to be somewhat impenetrable to anyone who doesn’t have a deep background in the field.  Further, because the authors liberally cite articles from medical journals – many of them well-respected, peer-reviewed publications – I expect that most people will assume that all the information presented is credible and accurate.  The articles are so well-done, in fact, that I had to do my own research to fact-check some of the more esoteric, plausible-sounding claims that conflicted with what I’ve learned over the years.

I think you can see why I feel unsettled.  The most egregious quackery on the internet is typically easy to spot and, once identified as such, can be given the weight it deserves.  But this particular thyroid site is in a different class.  At least 50% of what I read on the site is accurate information that is well-presented.  So how is a layperson – or even a medical professional who isn’t an Endocrinologist – supposed to distinguish which half is the bogus half?

Another unsettling aspect is I found material on the site that may be the genesis for some of the more ridiculous assertions I’ve seen disgruntled commenters leave on my blog, as well as elsewhere on the internet.  For example, the idea that mainstream physicians are practicing medicine that is 15-20 years out-of-date is promulgated all across the quack-o-sphere like it’s gospel.  Given that almost every comment of that nature is worded quite similarly, I had been wondering if people were getting this information from a single source.  Now, I have a suspect.

Why Your Doctor is Incompetent

In a polished, copiously-referenced post about why your doctor doesn’t know any of the groundbreaking stuff explained on the authors’ website, they posit that doctors simply don’t have time to keep up with all the developments in the medical world.  Worse, when we go to our annual medical conferences, there is no accountability, so naturally most of us will use the time in Vail to go skiing, or the time in Hawaii to go snorkeling.  Because we are too busy running our practices to read medical literature, and we’re having too much fun in exotic locales to attend lectures, we simply rely on what we learned 20 years ago in medical school and post-graduate training programs.

Clearly, I’ve heard this all before.  But this time is different.  This article backs up its carefully orchestrated attack on mainstream medicine with evidence.  First, it cites a 2003 NEJM (great journal!) opinion piece called “Clinical Research to Clinical Practice – Lost in Translation?”  Well, I went back and read the 2003 NEJM piece, and its message has clearly been manipulated into something that contains just a kernel of fidelity to the original piece.  Dr. Lenfant, who wrote the NEJM article, claimed that we can improve outcomes of many medical conditions by simply applying what has already been proven by research.  He offered examples of gaps between what treatments we know should be implemented and the actual prevalence of these treatments (e.g. low-dose aspirin for prevention of heart attacks).  He clearly states that we don’t know all the reasons why these gaps exist, and he calls on the medical community to figure out how to close these gaps.

Dr. Lenfant does not state, as claimed by the thyroid site’s authors, that doctors are uninformed about scientific findings and relying on what they learned 20 years ago.  The authors repeatedly and falsely claim that the original piece says that most doctors do not learn about medical discoveries by reading journals or going to conferences.  Dr. Lenfant makes it clear that there is a gap in applying the knowledge we have gained,  but he never says that physicians aren’t keeping up with the medical literature.

While this may seem like a benign, semantic difference, I assure you it is not.  The authors of the hit-piece on medical doctors have distorted and used Dr. Lenfant’s valid concerns to imply that mainstream medical doctors are incompetent, out-of-date, and ill-equipped to diagnose and treat subtle perturbations of thyroid function.  They do it in such a smooth, authoritative way that most readers will take it for granted that the referenced NEJM article condemns physicians in the same manner – it does not.  While Dr. Lenfant points out inadequacies in the health-care system that he says have numerous causes – some known and some unknown – the website’s authors portray Dr. Lenfant’s position as: doctors lack the ability to translate new research into action, and we fiercely resist new ideas that don’t conform to standard dogma.

The next reference used to support the authors assertions is attributed to an oral presentation delivered by a physician at a medical conference about dementia.  He allegedly said that most doctors are practicing 10-20 years behind the literature, among other things.  Interestingly, the only places I could find this alleged quote were on other websites referencing the site about which I’ve written today.  Curious.

After the oral presentation reference, there are several more citations that I consider weak references.  Then, the authors cite a 2005 Annals of Internal Medicine (another well-respected journal) review article which examines the relationship between a physician’s career length and quality of care.  The Annals authors do conclude that doctors “who have been in practice longer may be at risk for providing lower-quality care.”  It is an interesting read and should be taken seriously.  However, the thyroid site’s authors cunning use of linguistic jiu jitsu is, once again, impressive and effective.  They smoothly suggest that the Annals article’s findings support the idea that scientific evidence often directly contradicts the standard dogma of physician “experts.”  The authors are making a leap that I do not believe is implied by the Annals piece, and I am afraid that the casual reader will not pick up on that, simply accepting their conclusion.

The piece goes on in this vein for several more paragraphs, using credible references to score major points and advance the authors’ argument in a way that is not always supported by said references.  After reading their stunningly effective condemnation of mainstream physicians, I then read a couple of their thyroid-specific articles.  This is where the unsettling feeling really took hold.

Everyone has Hypothyroidism

As I said earlier, their informational posts about the thyroid contain a fair amount of accurate information.  However, they skillfully extrapolate and obfuscate the (patho)physiology to the point where an otherwise intelligent layperson will be slightly confused – but willing to buy into conclusions that appear plausible.  The problem is that the authors’ main conclusion that the TSH is often an unreliable blood test is actually in direct conflict with a huge body of thyroid literature.  More concerning, however, is that they do an incredible job of subverting confidence in almost all thyroid function testing.  Based on what I see every day in the office, this is what allows naturopaths and other fringe practitioners to diagnose absolutely anyone with hypothyroidism.  If blood testing is abnormal, you have a thyroid problem.  If testing is normal, it’s unreliable, so you still have a thyroid problem.  Using that logic, anyone with nonspecific symptoms such as fatigue and weight gain has hypothyroidism.

If there was a simple explanation for all the obesity and fatigue in the world, does it not stand to reason that obesity and fatigue would be rare?  Of course it does.  These symptoms would have already been stamped out with the liberal prescribing of thyroid hormone cocktails for all.  Now, some of the alternative medicine sites out there will tell you that treating hypothyroidism is hard and complicated, which explains why you haven’t felt any better under your regular doctor’s care.  You need to ask yourself: what’s the alty’s motivation?  Are they trying to sell you a book?  A plan?  A bag full of supplements?  Treating hypothyroidism is not that hard, folks.  There are nuances, to be sure – I’ve written about some of them before.  But if you have beautiful numbers on paper and still feel lousy, chances are it’s not your thyroid.

Doctors Don’t Keep Up-To-Date

Before I wrap this up, I’d like to address the pervasive misconception in the alternative medicine world that doctors routinely practice medicine that is 15-20 years out of date.  As stated earlier, this claim is used by the subject of today’s post to bolster their interpretation of the medical data.  The implication, of course, is that the authors are using the most up-to-date, cutting-edge medical evidence to guide their conclusions.  That sounds great – until you actually comb through their bibliography.  Out of well over 100 citations, 75% are from > 15 years ago, 25% are from 10-15 years ago, and – hold on a sec while I do some math in my head – 0% are from within the last 10 years.

Now, let’s contrast that with how professional societies like American Thyroid Association come up with revised clinical practice guidelines every few years.  The process is rigorous, you guys.  This is not simply a bunch of old, white dudes in a room slapping each other on the back, congratulating themselves on another publication for their CVs.  These guidelines are written by committees after reviewing hundreds (or more) of medical papers, including just about everything they can find on the subject.  Then, they grade each clinical practice recommendation according to a standardized scoring scale, so that the reader can attribute the appropriate amount of weight to the rec.  Recommendations that are based on expert opinion, as opposed to solid evidence, are graded as such.  Sure, there are plenty of “opinions” wherever the evidence isn’t strong enough, but that is always transparently communicated.

Some other time, we can certainly debate whether guideline-based medicine has the potential to fall short when caring for the patient sitting in our office – I am aware that this is a problem.  Today, my point is that most of the physicians I know do their best to practice high-quality, up-to-date medicine.  They do read journal articles.  They do change their practice style as the evidence evolves.  They do register for and attend continuing medical education conferences at which the latest data is presented.

So, Alternative Medicine, I concede that you’ve got some pretty slick players on your team.  You may even be kicking our ass right now.  But our players have more substance than style, and – more than that – we’ve got science on our side.

 

*In accordance with my site’s policy, I will not be naming nor linking to the subject of today’s post.  Any Comments guessing at the subject’s identity will be deleted.

 

Do you have any thoughts about the intersection of alternative medicine, mainstream medicine, and actual science?  Comment below!

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Image Credit: Photo by Daniel Fazio on Unsplash

16 Replies to “Alternative Medicine is Kicking Our Ass”

  1. Slick sites like that are becoming more and more common. I have been really amazed at the speed at which disinformation propagates. A good example of this is the MTHFR variation. So many sites will now tell you that you need “methylated” folate instead of folic acid. They will sell you these methylated folate and other B-vitamins. You can buy genetic test kits for just this one SNP that cost as much as a full genetic sequence from 23andme or similar companies. All of these sites will link back to a study that found that people with a certain MTHFR mutation have lower serum levels of folic acid after supplementation. Proof! Buy now!

    But the original study definitely does not conclude that alternative forms of folic acid are better-absorbed by people with MTHFR variations; all it concludes is that they MAY need MORE folic acid to reach optimal serum levels. Of course, it’s also possible that people with this variation have lower serum levels after supplementation for some other reason; it may be completely harmless and they don’t need more! But somehow, an incredibly vast mythology has sprung up around methylated folate and MTHFR and you can read the “journeys” of dozens, if not hundreds, of health bloggers to address their MTHFR status, get listicles of signs you may have the variation (if you don’t want to shell out for the test), and now every vitamin company and MLM is selling these supposedly methylated B-vitamins, some of which are in fact forms shown to be more *poorly* absorbed than folic acid.

    Every time I see another post about it on Facebook, I stand back in amazement that someone managed to literally create an industry out of thin air. The willingness of the health blogosphere to start making health claims based on pure, unmixed hearsay is terrifying. This is truly a disinformation age.

    1. Thanks, Sadie, for writing half of a post I need to eventually do on MTHFR. This comes up all the time from people who want me to either order it or tell them what it means after their alt med provider ordered it.

      1. I’ll be waiting for that one! If you write it, I’m pretty sure I’ll be linking to it at least once a day. My alternative-medicine-leaning friends are REALLY into that one; it ties into the idea that health is TOTALLY individual and standardised lab results can’t possibly apply to them.

  2. Dear HD:
    Love your posts, thank you. Just read your above “Alternative Medicine is Kicking Our Ass” and ‘their’ postulate that “doctors simply don’t have time to keep up with all the developments in the medical world” and in that vain was wondering your thoughts on genesight (I don’t want to hyperlink it but its a dot com) for both analgesic and psychotropic meds testing? Just had a patient tell me about it and rather dismissing it out of hand, wanted to get your take. Quackery or Legit?
    Thanx, iT O:-)

    1. Thanks, Ian. While I am aware of some pharmacogenomic testing that has been embraced in common practice (e.g. I believe gout is one example), I am not knowledgeable enough about the data for this testing in psychiatric disease to comment. I’d definitely have to do more research about that.

        1. Can’t believe I forgot to mention the genetic testing that’s being done to guide cancer treatments. That’s huge right now, especially for more advanced thyroid cancer.

  3. You should have one of your kids do a hash count on the ATA Guidelines and see how many of the recommendations are “weak recommendation” based on “low quality evidence”. Yet they are treated as one size fits all gospel. Not saying the research is “wrong”, just that much is not very good or poorly interpreted or proselytized for lack of better understnding.
    There is a comment in one (I will dig up the exact discussion if necessary) that the main reason that T3 monotherapy is not recommended is that there was only one study (which was actually a fairly well run one with good outcomes). Why is there only one study? Follow the money.
    The reason so many of the quacks are thriving is that endocrinologists drive them there. When the endo pats a thyroid cancer patient on the head and says “there-there” and won’t check Free T3 even with an undetectable TSH on high dose Synthroid and the patient is at risk of losing his job, more power to the general or “alternative” doc who brings the T4 into range and adds a little Cytomel or even (heaven forbid) prescribes NDT, all while keeping TSH in recommended suppression range.
    It’s upsetting to see formerly healthy folks put on cardiac meds to resolve the symptoms of overdosed levothyroxine, or prescribed an anti-depressant when their free T3 is way below low end of the range.
    Yes, the quacks and their catchy websites are selling snake oil but if you wonder why take a look in the mirror. They’re selling hope, you’re selling boilerplate.
    Hope to meet you at the Thyroid Cancer Survivors Conference in October – some of the best endocrinologists in the field will be there.

    1. I agree that it would be interesting to see how many of the ATA Hypothyroidism guidelines are based on “weak evidence.” Though I have not re-reviewed them recently, I don’t recall that “weak evidence” was an overwhelming problem. But, if someone out there wants to figure it out for me (sounds tedious!), I am willing to stand corrected if wrong.

      While I agree that guideline-based medicine has the pitfall of sometimes feeling like one size fits all, the best clinicians use guidelines to inform their decision-making process, as opposed to using the guidelines as a recipe to be followed regardless of what the patient looks like. For example, as I wrote in T3 Or Not T3 – Exploring The Controversy, I believe some patients may be candidates for T3 therapy, despite the fact that the guidelines don’t enthusiastically endorse it. This is a controversial area, however, because the evidence is not very strong.

      While patients may reach out to alt med in desperation, I do not believe that justifies the excessive lab-ordering and prescription-writing that I see alt med perform on a regular basis. While the Endo should not be “patting the patient on the head” and saying “there-there,” when the patient is clearly not ok, the Endo also cannot order a bunch of worthless tests (like T3 levels for assessment of hypothyroidism) and throw T3 pills at people when she believes that there is something else going on that’s non-thyroidal. Your implication seems to be that, by nature of not just standing there and doing something, the alt med provider is “right,” while the Endo is wrong. In reality, it may be the opposite. Or, they may both be wrong.

      Many providers in the quack-o-sphere are, as you say, “selling hope.” Unfortunately, in my experience, it is usually false hope. So patients spend time and money spinning their wheels. On the other hand, the best Endos are selling their evidence-informed clinical judgment. Sometimes, that fails to help the patient, and that sucks. But I take the position that it’s better to be honest and say, “I am not sure what’s going on with you, as I believe your thyroid regimen is optimized,” rather than put people through a battery of unproven testing and tinker with their T4/T3 regimen until they finally get fed up by nothing “working.”

  4. Thanks for a rather troubling article.

    I have a thyroid problem that is treated to give appropriate blood levels of TSH. I also have regular fatigue. But I have chronic pain due to abdominal adhesions and pain is tiring, even reasonably controlled pain is tiring. Would I like not to have fatigue? Hell yes, but whinging at my doctors to give me more levothyroxine won’t help, and could well be dangerous. In my case the cause of my fatigue is all too obvious, so I’ve never questioned whether my levothyroxine dose should be increased to sort it out. Sure it’s frustrating when you are told that doctors don’t know the cause of your problems, but trying to fix them by treating a different problem is unlikely to help, and means your real problem may be obscured to your later cost.

  5. Don’t tell the altys about the website “Up-To-Date”, where the medical information is current within 6 months, if I recall. I may have the details wrong as I’m a retired RN and have not been able to access the professional site for a year, but I loved it when still working. Pretty straightforward to find out the latest info on a given condition.

    1. Great point. UTD is awesome, and it’s what most docs use nowadays as a reference. So the argument that we are out of date is even less compelling when you consider UTD is constantly updated.

  6. Can you please write a post about the blasphemy that the [redacted] has about the thyroid! I am personally a fan of integrative medicine and soon will be a PA, but it would be great if you could write an article about it. The guy has absolutely no true medical knowledge and he’s like the new rage around a lot of my non medical friends. Driving me nuts.

  7. Less than 7 months ago you were making the argument for why MD’s should allow naturopaths and other alternative practitioners into their clinics and offices. That post hasn’t even dropped off your front page.

    Now given the fact that you, as a trained and practicing medical professional had trouble discerning the BS from reality, do you still think it’s a good idea to give these practitioners a larger presence in a legitimate medical setting? How would the average patient be able to know if such an integrated clinic was a MD who is trying to lead the ND out of BS or a MD who has given up on science and is fully pushing the ND nonsense?

    1. Well, I wouldn’t say that I was making the argument we should work with NDs, but I was questioning whether bringing them into the fold would help protect patients in the long run. That said, you make a fair point. The only way this works is for “good” MDs to bring in and train the NDs. Unfortunately, the average patient will have no idea how to assess this and would be at risk of having both a quacky MD and a quacky ND – double whammy.

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