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.
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