I recently spent the better part of a week in Chicago at ENDO 2018, one of Endocrinology’s largest and most robust annual conferences. I always enjoy this particular meeting, as it attracts speakers and attendees from around the world. The participants’ diverse experience provides alternative views to contrast with U.S. doctors’ understandably ethnocentric style of practice. When I say “alternative,” I am not invoking the quackery of the American “alt med” movement; rather, I’m talking about how physicians in other countries – and even in other parts of our country – have ideas that can improve the way we practice.
Readers not in the medical space may not fully appreciate how their physician’s practice style is heavily influenced by where she trained and where she eventually sets up shop. More concerning, however, is that doctors themselves sometimes don’t realize how many regional differences exist until they move somewhere new and gain exposure to the local standard of care. As a doctor who trained in four different institutions in different parts of the country for college, medical school, residency, and fellowship, I’m grateful for that geographic diversity. I think it helped me mature faster as a clinician, compared to some of my peers who completed three or four chunks of training, all in the same place. I realized early on that, as good as my training was, there is often more than one way to skin a cat; the way I learned was sometimes – but not always – the best or most appropriate.
My colleagues who have trained and stayed in one locale may give me some flak for the above statements, and I don’t mean to imply that they cannot be seasoned and utterly competent. There is an amazing doctor in my family, for example, who did college, medical school, and residency all at the same university, then stayed on to practice at that same institution. I maintain, however, that you don’t know what you don’t know – until you’ve practiced around the country (or world), practiced for a really long time, and/or been to enough of these international conferences that challenge what you think you know. Preferably, you’ve done all three, but two out of three is still pretty good.
So why am I telling you all this? I think it’s helpful to use as context for how what I learned at ENDO 2018 has the potential to make me not only a better clinician, but a better person.
Oh, puh-LEASSEEE…this is barf-worthy prose, HD. Is this going to be one of those “everything I ever needed to know I learned in kindergarten,” sappy, saccharine essays? Be honest with me! You’re losing credibility every second you hedge on this answer.
Uhhh…hm. You may have a valid beef here. How about this? I’ll make you a deal: you just skim the parts that don’t interest you, or the parts that lead you to taste a bit of bile in the back of your throat. If there is anything left to read at that point, hopefully you’ll extract something useful. If not, I’ll be happy to issue a full refund of this site’s subscription fee.
The Great Debate
One of the features of ENDO that I love is the debates. There are usually a few of these over the course of the conference, pitting one (inter)nationally-recognized expert against another. This year, my favorite debate was titled “This House Believes that Adrenal Vein Sampling [AVS] has a Major Role to Play in the Management of Primary Aldosteronism [PA].”
That was a mouthful. You’re losing me already, HD…
Hang in there. The good stuff is coming. Anyway, despite the fact that it seems like I’ve heard everything there is to hear about AVS for the management of PA, I knew I couldn’t miss this session. Why? Because the Maestro of Mayo Clinic (moniker assigned by me), Bill Young, MD, MSc was taking the position of “Yes (Almost Always).” I’ve been attending his lectures for well over a decade now, and this guy can craft a slide deck like nobody’s business. His presentations are never simply a bunch of text on a blue background; he creates something so dynamic and engaging that the end of his talks evoke the same feeling you get when a brilliant movie starts rolling the credits – you’re sad because you just didn’t want it to be over.
I entered that session thinking, “this probably won’t break much new ground, but I’m going to be thoroughly entertained for the next hour.” The debate started with the moderator using the audience response system to take a poll. He wanted to know, how many of the hundreds of people in that room believed that AVS is a critical tool in the management of PA? The result: about 85% said yes, while 15% said no. This came as no surprise, given that Dr. Young has been instrumental in crafting The Endocrine Society’s clinical practice guidelines for the diagnosis and management of PA. He’s also been lecturing about this for years at our national meetings, so the vast majority of us – including me – have already drunk the Kool-Aid.
Bill then delivered his talk, which was evidence-based, thorough, and even included video of him interviewing Mayo’s AVS Interventional Radiologist as well as a patient of Bill’s who benefited from his approach to care. No surprises so far. Entertaining? Check. Factual? Check. Reinforced my preconceived notions? Check.
Enter Paul Michael Stewart, MD, FRCP from University of Leeds in the United Kingdom, defending the position “No (Almost Never).” Perhaps it was the posh accent, or maybe it was the way he carried himself, but I sat up a little straighter in my seat when he began speaking. Over the next 15-20 minutes, he proceeded to lay out the most compelling argument I’ve ever heard for why AVS should not be the standard of care in the majority of cases. By the time he was finished, I was aiming my pleading eyes at Dr. Young, as if to say, “Bill, please tell me you’ve got the goods to refute all that. If not, I need to question the way I’ve been practicing all these years.”
In the rebuttals that followed, Drs. Young and Stewart each scored some points with me, but the moment of truth had come: the post-debate poll. We were asked the same question as in the pre-debate: should AVS play a major role in the management of PA? I, along with apparently many others, changed our initial votes to “no,” as the final tally showed about 63% voting yes, with 37% no.
So what’s the lesson here?
Dr. Young isn’t as awesome as you thought he was?
No, that’s not at all what I was thinking. He’s still just as awesome, and I still believe that AVS is an important tool for the evaluation of PA. For that matter, if my mother had primary aldosteronism, I’d want her under his care and that of his expert Interventional Radiologist. Without getting out into the weeds, I’ll simply say that AVS at Mayo Clinic is probably significantly more reliable than AVS at most other institutions, to the point where it might not make as much sense to pursue that testing outside of Mayo or another center with an incredible wealth of experience.
Again, what’s the lesson here? First, my regular readers know that I tend to get negative comments from alt med fans, along the lines of “you doctors stop learning after medical school; that’s why you refuse to use modern treatments like [fill in the blank with low-dose naltrexone, etc].” Or I get “if you would just listen to the 60,000 Hashimoto’s sufferers on quackythyroidforum.com, you would realize that desiccated thyroid is the right treatment; your refusal to use it clearly shows how much scorn you have for your patients.” I hope to show doubters that one of the reasons doctors go into medicine is that we love the concept of lifelong learning. In our world, we learn from rigorous, evidence-based debates like the one I described above. We do not learn from blogs that promote panaceas like low-dose naltrexone for every condition under the sun, nor from forums where the party line is paramount and dissenting voices are few and far between.
Second, the more important takeaway here is that the best physicians keep an open mind, even when we think we have it all figured out. For years, I’ve dutifully performed elaborate workups for primary aldosteronism, often getting non-diagnostic results on the adrenal vein sampling from my local center, wondering if I could even trust the results (despite working closely with one of the Interventional Radiologists to standardize their procedure). I’m now convinced that, unless I can get my patient to a center with a success rate similar to Mayo’s, AVS just isn’t worth it.
Am I distressed that I’ve been doing it “wrong” all these years? No, because it wasn’t wrong – and still isn’t. I just think that now, it is clearer to me that a different path may be the better one – at least for many of my patients. Learning something new at this stage of the game is intellectually invigorating, and it’s why I went into medicine.
Does this mean that I expect everyone else at that debate to follow my lead? Absolutely not. In the proper setting and experienced hands, AVS is a powerful tool that can guide the surgical management of PA. I believe every physician needs to weigh the pros and cons and then make an informed decision. If that decision involves performing AVS, great. If not, great. Whatever seems best for the patient at that time is the right move.
As I’ve written before, we need to be aware of our ingrained biases in order to move along the spectrum from intelligent to wise. Obviously, that applies to laypeople making decisions about their health, but it also applies to doctors helping guide their patients through these decisions. We all like to be right about the way we’ve “always done” things, so it takes an open mind and a willingness to listen to well-reasoned arguments to admit that our way may not be the best way.
Thyroid Cancer is not “Good Cancer”
One of the most compelling presentations of the week was given by a couple of thyroid cancer specialists who have been collating and interpreting data from the American Thyroid Association Thyroid Cancer Patient Survey. The survey is designed to “better inform medical providers about how patients experience the challenge of thyroid cancer diagnosis and treatment.”
The speakers were already starting from a disadvantage, as they were slated to be the last talk in a fairly dense day. Fortunately, they kept it light and full of surprises. I won’t recreate the presentation here, as it will eventually be published and available to the public for free. I will, however, mention a few things that struck me as especially poignant.
First, I learned that people who have been dealing with thyroid cancer don’t want to hear “it’s the good cancer.” This may seem obvious when staring at you in black and white (who calls cancer good?!), but it has never been obvious to me. I see many people whose diagnosis was made decades ago; when I ask them at the initial visit if they remember what kind of thyroid cancer they had, they often reply, “I don’t remember the exact name, but it was the ‘good’ one.”
When I diagnose a patient with thyroid cancer after biopsying a thyroid nodule, I often attempt to set her mind at ease by telling her some variation of “don’t worry, it’s typically a very slow-growing cancer that can often be cured with surgery and occasionally a dose of radioactive iodine afterward.” I’m pretty sure I have spoken the words, “if you have to get cancer, this one is one of the better ones to have.”
Patients have now spoken out through the ATA survey, and they are clear about one thing: when thyroid cancer is treated with a total thyroidectomy, it becomes a chronic disease (hypothyroidism) that needs to be managed lifelong, and that’s not “good.” In addition, because recurrences of thyroid cancer often need to be monitored for years – with all the attendant stress that comes with that – as opposed to immediately treated, that also argues against thinking of it as a “good cancer.” In our effort to reassure people that they are not likely to die or suffer major health consequences from this cancer, doctors have unwittingly presented this disease to patients in a way that does not jibe with the patients’ actual experience.
I was only somewhat surprised to learn that people feel like they were not educated nearly enough about what impact losing their thyroid would have on quality of life. Over the years, I have now treated enough people to know that, though most will do just fine without a thyroid, some people will struggle with decreased QOL that they attribute to not having a thyroid. It is my opinion that a portion of this group will have poor health due to other conditions that were temporally – but not causally – associated with their thyroidectomy. Nonetheless, there are clearly some people who just don’t feel the same post-surgery, regardless of the cocktail of thyroid hormones used for replacement therapy. The lesson here is that we should be counseling patients they might have trouble post-thyroidectomy, so they can make an informed decision about the extent of surgery to choose (sometimes it is appropriate to take out only half the thyroid, and now we also have the option to monitor some very small cancers without surgery).
In the survey, there were other opinions put forth by patients that reinforced one big picture concept: even though thyroid cancer is usually associated with very high survival and very low complications, for many people it becomes a chronic disease that separates their lives into two halves – before treatment and after treatment. According to this survey, patients feel like they’re not necessarily doing as well as they were led to believe. As physicians, we clearly need to work harder to educate our patients and set appropriate expectations.
Dispelling Internet Myths
If you’re still reading by this point, I’m going to reward you with some lighter fare. One lecture that I was very excited to see on the agenda was “Dispelling Internet Myths – What’s the Best Way?” Given my hobby, this was obviously right up my alley. My one concern was whether I’d have the self-control to not stand up and start proselytizing.
The speaker used a case-based format to illustrate some of our patients’ common misconceptions, as well as the bizarre treatment practices of alternative medicine providers (AMP). He outlined how he approaches the care of people who come to see him after having been treated by their AMP. Basically, he explains what he’s all about, which distills down to the fact that he practices evidence-based medicine. He is perfectly willing to explain to his patients why their naturopath’s testing and regimen is not recommended and why he believes that his testing and regimen is better.
What I – and many others in the room – found provocative is that he makes it clear to his patients that they need to choose. It’s either him or the AMP taking care of the patient – but not both. Some physicians in the audience expressed incredulity that this approach would be feasible. After all, there is intense focus in healthcare organizations on “shared decision making” and “patient satisfaction.” Some of us even have a portion of our salaries allocated based on patient satisfaction scores. It would seem that handing out ultimatums would not be well-received by the majority of our patients. Plus, by flatly telling people that they’re invested in quackery and need to divest immediately, they might interpret that as being called stupid. And people hate to be called stupid – especially by their doctor.
Despite the pushback he got from some audience members, the speaker stood his ground. Obviously, he feels like this approach works well for him. Whether his patients feel the same way, who knows? Though I certainly see the potential pitfalls in his approach, I have to admit that I would prefer to employ his approach compared to my current one. You see, even though I rail against quackery on this blog, I usually take a considerably more measured approach in my office. Sometimes my pulse and pace of speech quicken when I’m confronted with something beyond the pale, but I rarely utilize the “it’s my my way or the highway” approach. I do have some red lines I will not cross (e.g. I do not prescribe desiccated thyroid), but I have not explicitly told patients that I won’t follow along as they are treated in this manner by their naturopath, if that’s their ultimate decision.
Clearly, it would make my life much easier to issue ultimatums. It would save me hours of headaches – having to explain why the high reverse T3 level from the naturopath’s labs is meaningless, why the daily salivary cortisol result does not mean the patient has adrenal fatigue, and why the undetectable TSH level absolutely does mean that the patient is on too much desiccated thyroid. Issuing ultimatums would allow me to focus on the people I’m much more likely to be able to help, by allowing the others to choose the naturopath over me. There would be none of the nonsense I currently experience, in which I’m often asked to interpret labs I never would have ordered or adjust medications I never would have suggested.
So why does this “ultimatum approach” just not sit well with me? Part of the answer is that I often think I can convince someone that my approach is better, if only I can say just the right thing. Because I want to keep trying to make that breakthrough, I don’t want to alienate anyone. I want to leave that door open. I let people know that I don’t agree with the naturopath, and I don’t think the patient is doing the right thing, but when they’re ready to listen to me, I’ll still be there for them. I think that my patients with a proclivity for naturopathy appreciate the fact that I’m straight with them about my disagreement, but I’m also willing to continue seeing them if there is something they find therapeutic about seeing me.
Just so you don’t think I’m going totally soft in my old age, I want to make it clear that there are times when I strenuously object to a dangerous treatment plan and insist that my patient never see that AMP again. I have been known to use the phrase “this is absolute madness!” when dealing with people who I need to shock back into reality. But in the majority of cases, I tend to employ the more balanced approach I described above, despite the fact that it’s more painful for me on a day-to-day basis. Is my way better than the speaker’s method? No, I don’t think so. But it’s what I can live with, so it’s what I do.
So, readers, what do you think about the lessons I learned at ENDO 2018? Am I a better clinician for it? A better person? Still the same jerk I’ve always been? If you’re a doctor, what have you learned recently that surprised you or perhaps changed a strongly held belief? Comment below!
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