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.
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.