One of the commenters on my recent post, Low-dose Naltrexone – Hashimoto’s Cure or Powerful Placebo, said the following:
It’s STUPID, by-the-book doctors like you that I, and many Hashimoto’s patients avoid and feel contempt for, and whose opinions I throw into the trash immediately. Your blogs are now getting a lot of disrespect from one of the groups I belong to. Going so far as to say, by someone else, not me, that you should be reported. Good luck with your practice.
You’re a disgrace to the medical profession.
It’s not the most constructive comment I’ve received, but I’m glad she left it nonetheless. It shines a light on the chasm that exists between lame-stream doctors like me and many of our patients. In an effort to figure out if this relationship is salvageable, let’s see if we can understand why things go terribly wrong.
We are each thinking, “It’s not me, it’s you.”
The commenter claims to have contempt for doctors like me, avoiding us when possible, throwing our opinions into the trash on the rare occasions we must interact. Why the contempt? She’s not here to speak for herself (I’m open to a guest post from a reader’s perspective, for anyone interested), but I can guess.
It’s easy to see why people might have contempt for me when it comes to this venue, as my writing style is fairly confrontational. But what about me and all the doctors who are seeing patients in the exam room, trying to help? Obviously, there are physicians out there who don’t listen well or are poor communicators. I can understand why patients get frustrated with them, but I want to focus on the doctors who listen, synthesize the information, and conclude “It’s Not Your Thyroid,” or something else that the patient doesn’t want to hear.
If you’re asked whether you want a doctor who practices evidence-based medicine, you’ll say yes. But you don’t really want that.
It seems that one of the reasons why the commenter despises us is because we practice “by-the-book.” I would proudly agree that I am a by-the-book Endocrinologist, which means that I practice evidence-based medicine. That does not mean that I stopped learning after graduating medical school, as another commenter has suggested. It does mean that I make diagnoses and treatment recommendations based on the best medical evidence available. This evidence can be found in medical journals (not thyroid blogs), most of which are published on a monthly basis, chock-full of the most recent studies. In addition to reading journals, doctors attend continuing medical education (CME) conferences, usually several times per year. At these meetings, national and international experts in the field come to talk to us about the latest developments, what’s working, what’s not working, what we know, what we don’t know, and what directions need to be pursued for future research.
If I see a patient in the office and am not sure how to proceed, I can refer to clinical practice guidelines (CPGs), drafted by professional organizations like The Endocrine Society and American Thyroid Association. These guidelines synthesize all the medical evidence on a topic to-date, and each recommendation in the guidelines is graded based on a standardized scoring system. Recommendations based more on “expert opinion” than on high-quality clinical trial data are clearly graded as such, so clinicians like me know how much weight to give the recommendation.
Of course, there are plenty of times when a patient’s situation doesn’t fit neatly into a guideline; that’s when I use my clinical judgment, informed by evidence and honed over years.
Does that not sound like a reasonable way to practice medicine? I suppose one could argue that clinical trial data from Big Pharma-financed trials is suspect. I think it’s fine to be skeptical about the corrupting influence of money, but let’s not throw the baby out with the bath water. Trials that are published in peer-reviewed journals are scrutinized by reviewers, editors, and readers. These trials are also discussed in “journal clubs,” held at all academic institutions. This is where a medical student, resident, fellow, or attending physician presents a single paper to a group of doctors, and then they all see if they can rip it apart or if it holds up (this is more or less how journal club works). My point is, if you are going to dismiss medical research as hopelessly biased, we might as well just return to the days of drilling holes in the skull to release evil spirits (see trepanning).
There is always going to be some form of bias in research, folks. It’s up to critical thinkers (like doctors) to recognize the bias and make an educated decision about how much that bias has affected the conclusions of said research. The presence of bias does not mean, however, that tossing all that research into the garbage is a valid strategy.
Fringe practitioners will tell you what you want to hear; medical doctors will tell you what you need to hear.
Why do people enthusiastically adhere to what they read on blogs and what their naturopaths say, while sticking their fingers in their ears, scrunching their eyes shut, and screaming “Nah nah nahhhhhh…I’m not listening to youuuuuu…” when a well-educated physician tries to help?
I think it often has something to do with the fact that medical doctors are very good at figuring out what patients don’t have. We are not always great at figuring out what patients do have. Why? Because there are usually a limited number of plausible diagnoses for most patients’ presenting symptoms. If we test for everything that seems plausible (and maybe even a few oddball possibilities) and all testing is negative, then what we can do at that point is explain that we haven’t found objective evidence to support a diagnosis. Of course, as I’ve stated in prior posts, I believe that many symptoms are related to lifestyle issues like poor diet/exercise/sleep and stress. We can certainly test the waters as to whether the patient will be receptive to that line of thought; unfortunately, she typically is not.
Granted, our messaging could be better. When I say, “I can’t find a hormonal explanation for your symptoms,” the patient often hears, “There’s nothing wrong with you.” I can see how that would be frustrating, as patients like to feel validated, at the very least. I now make a point of reassuring the patient that I believe her symptoms are real, but I just can’t figure out the cause.
The big problem here is when a patient has been told by numerous doctors, “I can’t find anything wrong with you,” and then a naturopath, “functional medicine” doctor, or other fringe practitioner comes along and says, “I know exactly what’s wrong with you.” The patient loses faith in conventional medicine and is likely to call into question the validity of all the negative test results. What often goes unsaid is that the fringe practitioner is making a diagnosis based on…what? Instinct, symptoms only, dogma, manipulated data, etc. The approach lacks any semblance of intellectual rigor, but people eat it up, because it gives them what they want to hear – answers. Sadly, most of these “answers” will prove to be wrong, over time.
Using the above logic, medical doctors would have much better relationships with our patients if we would just hand out more diagnoses. Unfortunately, the Hippocratic oath doesn’t work that way. So what can we do to help patients when the by-the-book approach fails to elucidate a diagnosis? This is where it gets incredibly challenging, especially when patients are convinced they have a hormonal problem and completely resistant to the idea it could be their lifestyle.
I suppose doctors can start by making the patient feel heard, as I stated earlier. We can also explain that we don’t know everything – it’s possible, for example, that there are undiscovered or subtle perturbations of the endocrine system which cause symptoms but won’t show up in our current testing. Why not admit that? It’s possible, right? We should simultaneously be clear that, if we can’t find evidence of a hormonal disorder, then we can’t treat for one just because it sounds like that’s what the patient has (“hypothyroid” symptoms could reflect almost any condition, after all). We can offer a sympathetic ear. We can suggest other avenues for getting answers if we have other ideas. We can offer to retest/revisit the issue if symptoms persist over time or worsen.
In my experience, however, none of the above will satisfy the type of patient who does her research using blogs and belongs to a forum that hates doctors like me. And that’s why I’m afraid that our relationship is unsalvageable – her naturopath will always be the hero, swooping in with a ready diagnosis and a fist full of hormones and nutraceuticals. As an evidence-based Endocrinologist, I will always be the villain – too stupid to make the right diagnosis and too insensitive to care about my patient’s well-being.
I just can’t see how there is a satisfying answer to this problem, but if anyone has it figured out, I’m all ears. Comment below!
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