I received the following, single-sentence comment in response to one of my recent podcast appearances: “Are your patients doing well or were they doing well?”
I love this question because it’s deceptively simple, with its exploration leading to the plowing of some fairly fertile soil. So please hang with me while I bang out this post in a stream of consciousness state; I know — it’s not my usual modus operandi.
One way to rephrase the commenter’s question is: “Given your copious criticism of the way alternative medicine practitioners diagnose and manage conditions like hypothyroidism, do your patients do any better with your approach, under your guidance?”
That’s a totally fair — if somewhat confrontational — way to phrase the question. The easy and most tempting answer for me and most of my mainstream physician colleagues to give would be, “Yes,” full stop. But that would be a half-truth, at best.
In order to really dig into this issue, we have to define what it means for a patient to be “doing well.” The answer to that gets real muddy real quick, as it relies partly on objective, measurable criteria and partly on me judging someone else’s subjective state of being. My best attempt to answer the question would be guided by one of the following two definitions of “doing well”:
- The patient feels noticeably or significantly better under my care, for at least six months, with objective testing within normal ranges or at least moving in the right direction.
- The patient feels no better or worse under my care, but my medication adjustments have resulted in the improvement of laboratory values that were previously way outside the normal range1.
Note what isn’t in my definition of doing well — the patient likes me or is happy with his/her care. As I have previously explained here and here, patients often misjudge the quality of care they receive when using the above variables to evaluate said care. Stipulating that, I have generally found that most patients fulfilling one of my two definitions of “doing well” like me and are happy with their care.
So, would I say that my patients have done well over the years? Many have, but some have not. Any medical practitioner, mainstream or otherwise, who claims to know the percentage of her patients who improve under her care is deluded at best, lying at worst.
I’m sure that the vast majority of patients who feel they haven’t improved under my care simply go somewhere else. This leaves my interpretation of how well my patients do open to sampling bias, since my long-term patients are more likely to be those who believe I’m providing excellent care.
This is one of the fundamental reasons why all the alt med gurus in the quackosphere, touting unrealistically high rates of success with their protocols, should not be taken at their word. While there are certainly other reasons to distrust them — like the fact that a huge proportion of their clients will initially have a dramatic placebo effect that wanes over time — you must keep in mind that the vast majority of alt med’s failures are invisible to them, due to client attrition.
Conclusion
Much like the statistic that 88% of American drivers consider themselves above average, I’m willing to bet that the percentage of physicians and alt med providers who believe the vast majority of their patients do well is improbably high. And with that caveat being equally applicable to me, my reply to the OP is “Yes, my patients have done well under my care.”
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- For example, many patients have come to see me with raging iatrogenic thyrotoxicosis (i.e. taking dangerously high doses of thyroid hormone), and I have been able to slowly wean the dose. This may or may not be associated with significant symptom improvement, but it is almost always associated with a reduction in the risk of complications like atrial fibrillation. I view this as a win. [↩]
“I’m sure that the vast majority of patients who feel they haven’t improved under my care simply go somewhere else. ”
Yup, that applies to so much and makes these questions really difficult. It hit me when listening to some random podcast where it became apparent that the “coach” would actively fire they didn’t like / didn’t get along with. They have a 100% success rating : )
But another thing is people that get better on just placebo / nocebo treatment. While I don’t think this is a huge amount, it is non-trivial.
Keep up the great posts!
John
Totally agree about the placebo/nocebo effect. I try to control for that by defining success as someone who does well for at least 6 months, as most placebo effects will wane by then.
Thanks for answering my question and thank you for this blog and all the information that you give us.
Would you agree that Endocrinologists primarily focus on situations where a primary care doctor is having difficulty (if we are talking thyroid here). Or situations where the labs do not make sense (finding reasons for strange lab results). What’s hard for you is did they stop coming to you because your care was poor? Or did they stop coming to you because you solved their issue and they returned to their primary care doctor? I myself found a pretty good endocrinologist who bumped up my medicine and found the right dose for me. I wasn’t planning on leaving her, but she left her practice to go somewhere else. However, I was stable and doing well so I just had my primary care doctor take over the management. Personally I think most people just haven’t found the right dose (can be quite narrow). Although I’m sure there are some people that require a bit more (as you’ve described in your T3 blog posts). I don’t believe all alternative ideas are false, but after many years of this I am cautious on a good amount of it. I use a combination of alternative and conventional and am in a really good spot nowadays.
You raise some good points/questions, Mike. While I would often attempt to transition people who were stable and doing well under my care back to their PCPs, I found that some of them were amenable to that, but many wanted me to continue managing their thyroid medication. I think at least part of the reason is that, after (often) years of not feeling normal/stable, people can be reluctant to turn over the reins to anyone other than the doctor who finally helped them feel better. I had many patients who became visibly anxious when I suggested that they might not need me anymore.
As for other Endos, I think many of them have practice styles similar to mine, in that they try to free up their schedules for people who really “need” them. This is because there are generally not enough Endos to meet the demand, so we do need to be available for new patients. Waiting 4-6 months to see an Endo is an unacceptably long period of time for many people.
There may be some Endos in private practice who are trying to build their practices, and I suspect they would be happy to continue seeing “easy”/stable patients indefinitely, or at least until they become too busy to sustain that type of practice.
You’re right, though, in that I would often get consults for discordant thyroid function test results (they didn’t “make sense” to the PCP), and I would often see these patients just once, if the explanation was fairly benign and didn’t need further workup/treatment.
The anxiety makes a lot of sense. I can understand someone wanting to stick with someone who fixed their problem, just in case some adjustment is needed in the future. Especially if they had bad experiences in the past. The good news is those patients should be pretty chill for visits. Probably once a year would be OK and maybe test every 6 months if needed. I know for me it took a few years to find the right doctor. However, at this point my dose has been stable for a few years and unless something changes I should be good for a long time I hope. Things can change and I have seen other folks have issues with random dose changes based on a test. My sister had this happen (and a friend of mine) with a very low TSH all the sudden. However, I asked her if she had biotin before the test and she said yes (my sister). She still went with the dose change and her next TSH was really high and she felt terrible for awhile after that. I think before a dose change there should be a retest to ensure it was accurate (and make sure there was no interference). That to me is the biggest risk to a stable situation. Dose changes when the patient feels good but a test comes back funny.
Very reasonable suggestion.
Check out new Hypothyroidism book https://press.uchicago.edu/ucp/books/book/chicago/R/bo183892827.html