Mainstream Medicine Needs to Play Offense

Last summer, I published a post called Alternative Medicine is Kicking Our Ass. In it, I focused on one particularly slick alt-thyroid site that has done a masterful job of sowing doubt regarding the advice mainstream physicians give to our patients about the thyroid. Not only that, but the site has called into question our competency as doctors, citing “evidence” that supposedly proves (it doesn’t) we are all practicing medicine that’s 20 years out-of-date.

My mind wandered back to this post recently when I had the following interaction with a new patient: a 60-ish year-old woman came to see me for a consultation about her thyroid treatment. She immediately handed over a piece of paper with pretty much every thyroid lab test that can be ordered – and of course she wanted me to order all of them. She then launched into a lengthy soliloquy, quite matter-of-factly explaining how she knows that mainstream doctors don’t really understand the thyroid…and so on.

Although I have countless interactions of this nature in my practice, I was particularly struck by this woman’s tone and posture. Upon reflection, she wasn’t accusatory, nor was she antagonistic. She also wasn’t curious about my opinion; she wasn’t asking, “What do you think about what I’ve read?” She was simply presenting her “research” to me in a way that said, “Listen, I’ve done my homework, so I just need someone with ordering authority to whom I can hand off the baton for the next leg of this relay.”

The way that she spoke to me was almost – but not quite – conspiratorial. I’m straining to capture this interaction accurately…it was like she was saying, “Hey, I know mainstream doctors don’t know about treating thyroid problems. You know mainstream doctors don’t know about treating thyroid problems. Let’s work on this thyroid thing together, since we both know there’s a better way.”

It took a mighty effort to conceal my incredulity, as I wanted to blurt out, “You do know that I’m a ‘mainstream doctor,’ right?!”

It is interactions like this one that have convinced me that Mainstream Medicine (MM) can no longer ignore Alternative Medicine (AM), nor can it be content with simply playing defense when a patient comes in sporting dubious research that she wants incorporated into her treatment plan. Patients are reading AM websites with information that is so plausible – and so ubiquitous on the internet – that the problem is no longer that they’re accepting this information at face value. It’s worse than that. They are also assuming that their research is so authoritative and unassailable that those of us who practice evidence-based medicine have come to the same conclusions. Or, if we haven’t come to the same conclusions, our patients believe that they can educate us about the “right” way to approach endocrine care. Folks, Mainstream Medicine needs to start playing offense.

In MM’s defense, it has published some fantastic works that address AM’s misguided approaches to treating patients. For example, the American Thyroid Association did a deep dive into why some patients struggle on their levothyroxine replacement therapy despite “optimal” blood levels, culminating in a well-researched, meticulously-cited 2014 guideline paper. The authors did a great job explaining where we are with the research, where the gaps exist, and what questions remain to be answered.

There is a wealth of information in that paper that can be drawn upon to refute common assertions by AM about how to diagnose, treat, and monitor hypothyroidism. So what’s the problem? Most laypeople will never read it. Granted, guideline papers are generally geared toward professionals in that space, which is appropriate. What’s no longer appropriate is to bestow sole responsibility for educating patients onto physicians. At this point in the techno-age, the physician is becoming a middleman. Sure, the doctor is an important middleman, but patients know how to do a Google search. Given that the average user won’t go past the first five results on the first page, if AM sites rank higher than MM sites, then none of MM’s great information will be seen.

Though I am not an expert on search engine optimization, I suspect that one reason why AM sites rank highly is because they are written for laypeople. They typically use language, keywords, and tags that match terms people type into search engines. These posts also address why people don’t feel well when their doctor tells them “everything’s normal,” which is unsurprisingly compelling to someone looking for answers.

Unfortunately, MM sites written for laypeople give accurate information,  but they do not usually address myths and misconceptions. This leaves a tremendous void that AM is happy to fill with nonsense galore, to the point where – for example – there is tons of information out there about why one should take pig thyroid (one shouldn’t), but there isn’t nearly as much information debunking these assertions.

It is my contention that MM’s professional societies – which are incredible resources for both patients and medical professionals – need to focus more on refuting AM’s claims. How could this be accomplished in a meaningful way? They should put out information in formats that laypeople actually read, listen to, and watch. This means that they need to prioritize direct-to-patient education and invest in the human capital necessary to create and disseminate this content.

Not that I’m auditioning for a job here, but if The Endocrine Society or American Association of Clinical Endocrinologists decided to pair up a physician and a savvy tech/marketing person, I’m pretty sure they could come up with ideas for blog posts, podcasts, and videos that would be both compelling and educational.

If our professional societies believe that our mission as physicians is to lead people toward better health, then they need to step up and steer people away from Alternative Medicine. It simply isn’t fair or practical to shift the entire burden to physicians, who spend more time in the exam room telling patients what they don’t have, with little time left to focus on what might actually be causing their problems.

Do you think that MM has an obligation to more aggressively refute AM’s claims? How do you think that can be accomplished? Who should take the lead: bloggers, professional societies, individual medical practices? Do you think that people who don’t trust the conventional medical system will even read anti-AM information, or do you think they’ll simply stick to information that tickles their confirmation bias? Is it worth it to put out anti-AM content for people who are seeking the truth, regardless of who is right? Comment below!

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Image Credit: Photo by Sharon McCutcheon on Unsplash

26 Replies to “Mainstream Medicine Needs to Play Offense”

  1. Absolutely 100% worth it to fight this battle. I fell down this rabbit hole of AM myself, and even tho I’m out of it, I still on occasion fall for one of their claims and look into their websites. I say this to my husband, who is a surgeon, why isn’t MM louder than AM? Him being a surgeon is a different practice than yours so he doesn’t encounter a lot of crazy treatment plans from patients. Keep up the good fight.

  2. If you look at the series ‘A User’s Guide to Cheating Death’ by Tim Caulfield, he does a great job of myth busting educating. His goal is to do exactly what you mention, sexy up the boring, and bore down the woo.

    Insightful post as always, thanks!

  3. Thanks for posting the link to the guideline. I skimmed it and dove deep into the questions that were relevant to me. Very informative but painful.

    If there were a MM site that had a nice infographic showing the guideline info with associated strength of evidence and links to the details that would be fantastic. Examine.com is a great example of how to summarize evidence graphically.

  4. Great column, as usual, HD! As a very mainstream nutritionist/evidence reviewer, I fight this same battle constantly and constantly puzzle over how to up my communication game. In addition to counseling and teaching, I use my blog to dissect AM claims as well as the sound bites that appear in the mainstream media, but mostly I’m preaching to the choir. I believe our most fearsome foe is the smug certainty with which AM practitioners dole out answers and supplements and lists of recommended lab tests (which of course they themselves can’t order) to patients with conditions for which we know there are no easy answers, conditions that are devilishly difficult (if not impossible) to treat or for which the treatments involve sometimes major lifestyle changes. I agree we need to go on the offensive with easier-to-understand info…and maybe some messages of hope?

  5. I think it’s a combination of all of the above. MM practitioners probably need to use their first hour consultation to bore down the woo per say and address each of the patient’s issues. There should be a lot more blogs like this – I had to hunt far and wide and haven’t found anything else even slightly comparable. And finally, Pharma companies who seem to fund a lot of HCP education probably need to communicate directly to the patient, pushing mainstream medicine as they do, but also debunking the AM myths. It’s definitely a different way of working for all involved and won’t happen overnight. But you’re right – MM needs to acknowledge that they’re losing the battle and step up.

  6. I’m curious as to your response when a traditional doctor falls for the alternative treatments and forces the pig thyroid medication on a patient who really did not have a thyroid problem? I thought I was receiving competent medical advise and instructions. I cannot begin to tell you how horrible my life has been after more than 30 days in a medically induced over active thyroid state brought on by 5 days of thyroid medication called Nature Throid. This so-called traditionally trained doctor, not an alternative medicine practitioner would not listen to me when I told him the side effects I experienced from the thyroid medication. He told me I “had to take it.” I discontinuedthis medicationand got a second opinion, which no doubt saved my life.

    1. That’s such a great question. When MM providers do stuff that smacks of alt med, it drives me nuts – way worse than when I’m cleaning up AM’s mess. I do hold MM providers to a higher standard, as patients trust that they are getting “competent medical advice.” Further, I’ve found that patients who have been diagnosed by AM with a thyroid or adrenal condition will often seek a second opinion with an Endocrinologist. But if a mainstream doc makes the same diagnosis, the patient may only seek out another opinion if she’s not doing well on the treatment that was initiated.

      In my organization, we had a general medicine provider (gone now, thankfully) who fancied herself more of an “integrative medicine” practitioner. What this meant in real terms, I don’t know. But what it meant for my practice was that I had to re-educate many of her patients that they didn’t need 6 different thyroid function tests checked every time they got their blood drawn, etc etc. When I complained to her medical director, I got “Well, I hear you, but she’s really good with our toughest patients, and she doesn’t always do strange things.” This makes it even harder to swallow, as how are patients to know when they’re getting the “good” advice vs the “wacky” advice? I actually explore this issue in the following two posts:

      Why Subspecialist Physicians Go Rogue – Part I

      Why Subspecialist Physicians Go Rogue – Part II

      To finish off this comment, let me also say that the patient I described at the beginning of this post did not actually have hypothyroidism. I had access to her pre-treatment labs, which were stone-cold normal. These were the labs upon which her diagnosis was based and treatment was started (by AM). It took a long time to patiently explain why I never would have made the diagnosis in the first place, because she was already convinced that “the usual” normal thyroid tests don’t mean that you’re normal. I had to individually debunk every additional test that she believed would make her diagnosis, sort of like recreating my posts about rT3, antibodies, T3, etc in the exam room. But that’s what it takes sometimes.

  7. Hear, hear! As a practicing allergist facing many of the same challenges as you, this particular post really resonated with me. This is a totally actionable item that our subspecialy organizations can accomplish. I urge you to forward this post to the Endo Society!

  8. Even though it is not AM , hard to fight the good fight when Big Pharma is sinking the serious dollars into direct to patient advertising – have you seen the new one on narcolepsy? This feeds into the whole problem.
    But alas , fight on we must . Thanks HD

  9. I’m taking 1.5 grains porcine thyroid extract plus 100 mcg levothyroxine instead of 175 mcg levothyroxine, with my doctor’s knowledge, as liothyronine is so expensive in my country I would never be allowed a trial. My dose equates to about 152 mcg T4 + 12.5 mcg T3. Benefits include normalized bowel motility; improved body temperature; reduced oedema; normalized time to ejaculation. Cholesterol and triglycerides normalized, though only tested once per year.

  10. Message from the UK.
    I think MM should be much more forthright about the uselessness of AM. Sources such as NHS England, NICE and the various Royal Colleges and specialist organisations make a reasonable fist of it. However, many patient support charities are very happy to provide information about AM, and even if they make some sort of statement such as “we don’t know how acupuncture (or whatever) works” the fact there is a booklet about it gives it credence.Unhappily, many of our popular TV programmes on medical issues are fair less damning. I saw one recently that compared CBT with acupuncture as approaches to ceasing smoking. The person using acupuncture seemed to have more success. So there you are – acupuncture works because it was on TV.
    I think a problem at the patient/doctor level is that many people present with conditions that can’t be cured. Take lower back pain. In most cases the treatment option (in the absence of any discernible aetiology amenable to treatment) is to keep active and use painkillers. No matter what the doctor says, a fair number of people will seek a cure from some AM merchant and end up convincing themselves that AM makes them feel better.

    1. Great points, Stephen. I agree that many conditions will run their natural course and resolve, but the resolution will be attributed to the AM intervention instead of the body’s tendency to heal itself over time.

      MM really needs to beat some of the messages home more forcefully, as you suggest. We need to be louder than the other guys, which is hard when they’re on TV.

      1. You bring up that AM is on TV. I’m wondering exactly what you are referring to, because when we watch TV in the US, we are constantly seeing television commercials for pharmaceutical drugs, and Cancer Centers, etc. I find that these commercials, which I believe are associated with MM, make me feel less confident about MM.

        1. When I mentioned that AM is on TV, I was referring to Stephen’s comment about TV programs in the UK that promote AM or are not critical enough. To your point, S, I also find much of MM’s advertising distasteful. I can see why it would make you feel that way.

          1. The overwhelming number of drug commercials makes me think that the pharmaceutical companies want the viewer as a patient to self-diagnose and then go to a doctor and say, “I have xyz, and according to this tv commercial, I should be taking the abc drug.” These commercials also try to make us think that the MM doctor is just a mach8ne to write prescriptions for televised medications.

  11. In the UK, there is no advertising for prescription drugs to the public as regulations forbid it. So we are spared the cringeworthy mini dramas I see when I am holidaying on the USA.

    However, products generally on sale to the public through pharmacies OTC – over the counter, without prescription, can be advertised. These tend to be for itchy bottoms, constipation, colds and general pain relief.

    Our advertising codes are quite strict. For example for homeopathy “To date, the ASA has have not seen persuasive evidence to support claims that homeopathy can treat, cure or relieve specific conditions or symptoms. We understand this position is in line with other authoritative reviews of evidence.” So homeopaths cannot advertise that they can treat anything specific.

    Advertising as such is not a major issue – rather it is TV and radio programmes that promote woo-dom.

    ASA = Advertising Standards Authority.

    1. Very interesting. Actually, it seems more advantageous for alt med’s desire for credibility to be discussed on a program, as opposed to being promoted in an ad. I think people are more likely to be swayed by a program (it’s on TV, it must be true!) than an ad.

  12. It’s almost like someone should invest the time to make infographics/Pinterest pinnables with actual facts for direct to patient education or something… what a brilliant idea, if I say so myself!

  13. I had an idea while reading this article.
    I have multiple disorders, and I’ve had to learn to be an effective patient. I run a mental health website whose mission is to educate people about coping well with mental illness. I recently wrote an article about how to be an effective patient. Many people with both blogs and disabilities have learned these skills already. These include things like writing down symptoms and bringing the list with you to the doctor, writing down questions beforehand to make every minute count, trusting the doctor, and if you don’t wind up being helped by the doctor, don’t write off MM, just get a second opinion from another MM doctor. I will try to rally disabled bloggers about the need for articles that talk about how MM helps them, how to be an effective patient, and give examples of how they healed and improved. This doesn’t have much to do with AM, just support of MM. It’s not much, but this is something I can/will contribute to the situation.

    1. That’s great, Emily. I think learning how to be an effective patient is a critical skill to acquire. Thank you.

  14. Great post. I think one reason people go to an AM practitioner is because they are not getting answers or help from their MM practitioner. I have a couple of very unusual symptoms that don’t even have names because they are so unusual (one of which could very easily be thyroid related) as well as other run of the mill symptoms (body aches, fatigue, loss of hair). I have seen my PCP several times as well as specialists yet none of them has a clue what is wrong with me, so they write it off as “anxiety” or “migraine,” give me some pills and send me on my way. I don’t want to treat the symptoms, I want to know the cause and treat that so I no longer have symptoms. My issues are real and disabling and are not related to anxiety. If MM doesn’t know what the problem is and doesn’t care to find out what it is and chooses to do nothing except give you pills what is one supposed to do? I think this is the reason many turn to AM, they are looking for someone who can give them a name for their disease. Unfortunately it usually come with a big price as these visits aren’t covered by insurance and they also like to give you pills in the form of very expensive vitamins and in the end you really aren’t any better off. At this point I’m not real happy with either MM or AM.

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