Whose Health is It Anyway, Tony?

A Response to AP Weetman's 3/06 Anti-Patient Editorial in Clinical Endocrinology

"Nothing seems more straightforward than treatment of hypothyroidism..." -- Tony Weetman.

In a stunning display of medical condescension, endocrinologist AP "Tony" Weetman, Dean of the Medical School at the University of Sheffield in the UK, has written a derogatory, anti-patient editorial on thyroid disease, titled "Whose Thyroid Hormone Replacement is it Anyway?" It's a frightening view into the mind of many of today's endocrinologists, and the tired dogma that guides how they practice, but it's a must-read for any informed patient.

It's available online at Medscape (free login required), and published in the March 2006 issue of the journal Clinical Endocrinology.

It's All In Your Head

In his editorial, Dr. Weetman states that patients who have "normal thyroid function tests" but insist they should be treated for multiple thyroid symptoms actually have "somatoform disorders." Sounds very medical and official, right? But make no mistake..."somatoform disorders" is medicalspeak for hypochondria. That's right. Weetman is saying is that if your tests are normal -- and apparently, even if you have a host of thyroid symptoms, a family history, and a goiter the size of a melon -- the diagnosis is simple and straightforward: you have a psychiatric condition. Yes, it's all in your head.

Why is it so easy to write you off as a mental health problem? Because "nothing seems more straightforward than treatment of hypothyroidism," says Dr. Weetman.

According to Weetman, "we have robust assays to diagnose the condition and an effective replacement in the form of synthetic thyroxine."

Dr. Weetman doesn't explain, however, how it's all so straightforward. For example, consider the Colorado Thyroid Prevalence Survey, which found in 2000 that an estimated 13 million Americans may actually have an undiagnosed thyroid condition.

 

And if synthetic thyroxine is such an effective replacement for the real thing, why, in the Colorado study, did they find that among patients taking it, only 60% were within the normal range of TSH? (And this was according to the old .5 to 5.0 standard.) And why did the Thyroid Foundation of America find in a study that more than half of all Graves' disease patients suffered what were obvious thyroid-related symptoms, after having radioactive iodine and being stabilized on levothyroxine therapy?

The reality: It's not as straightforward as Dr. Weetman seems to believe.

What IS Normal?

Despite dismissing patients with normal thyroid levels and symptoms as having mental health problems, Weetman never actually defines or identifies what "normal" is. This exposes one of the biggest flaws in his argument. Because he cannot declare that symptomatic patients have mental health problems if they have "normal thyroid function" if he hasn't even established scientifically what normal is.

The fact is, endocrinologists cannot even agree on what the so-called normal range is for the popular "TSH" test.

The TSH Reference Range Wars have been raging for several years now, and show no signs of a cease fire.

Even today, you can ask two equally qualified endocrinologists to interpret the results of a patient with a TSH test score of 4.0. One doctor would say that patient was hypothyroid, and the other would have to, according to Dr. Weetman's logic, declare that the patient does not have a thyroid problem, but rather, has "somatoform disorders" and requires mental health treatment.

So, following objective fact -- a process Dr. Weetman holds up as the scientific ideal -- yields two opposite, yet supposedly equally valid diagnoses and courses of treatment.

Is it any surprise then, that patients are, as Dr. Weetman says, "dissatisfied with and mistrustful of standard medical advice." Because, depending on which doctor you talk to, for patients with a TSH of 3.1 to 5.0, they are being diagnosed and treated according to two totally opposing objective standards. This is science? I'm afraid not. It's actually plain ivory tower arrogance, with a little insecurity thrown in.

The problem is that endocrinologists like Dr. Weetman have found themselves incapable of properly diagnosing and treating their patients, or effectively resolving their symptoms. Rather than seeking to research and understand the problem, they fall back on the oldest trick in the book -- blame the victim. "We can't explain it, so it must be in their heads."

Healthism is Here to Stay, Dr. Weetman

Weetman arrogantly blames what he calls "the rise of 'healthism.'" Dr. Weetman describes "healthism" as:

"high health awareness and expectations, information seeking, self-reflection, distrust of doctors and scientists, healthy and often alternative lifestyle choices, and a tendency to explain illness in terms of folk models of invisible germ-like agents and malevolent science."
--Dr. Weetman, describing "healthism" in the editorial

And here you have it, folks. When you look at Dr. Weetman's list of patient flaws [not surprisingly, many of us would consider them to be compliments!], and you can see that by looking at their exact opposite qualities, you have the "ideal" patient for a doctor like Weetman.

  • Low health awareness, low expectations: That way, you will take whatever you can get, you won't take up too much time, you'll be satisfied with anything a doctor like Dr. Weetman says or does, or prescribes, and Dr. Weetman and friends don't have any expectation to live up to.
  • Non-information seeking: If you don't seek information or come in with information, then you will be docile, relying on Dr. Weetman and his cronies to provide the information. You won't have anything else to compare it to, so you're forced to believe the doctor, accept what he says, and not question it. What a pleasure you are as a patient!!
  • Lack of self-reflection: If you are not self-reflective, then you're probably not spending too much time thinking about whether or not yodeserve to feel or live well, you don't think about what you can do to help take charge of your own life and health. Go to the doctor, and accept what is said without question. Dr. Weetman loves patients like you!
  • Total trust of doctors and scientists: If you trust doctors and scientists, then you won't have any questions about whether they have conflicts of interest, or whether they being influenced or biased by drug companies, or perhaps, uninformed, uneducated, lazy, or sexist, or whether they are just plain wrong.
  • Unhealthy lifestyle choices: This one is simple. If you make unhealthy lifestyle choices, then you create more business for the doctors and the drug companies. Who's going to write checks to Dr. Weetman if they're too busy out there eating well, exercising, not smoking, and taking care of themselves?

  • Alternative lifestyle choices -- Another easy one. If you are doing "alternative" things -- everything from vitamins and dietary changes, to holistic approaches -- and you are feeling better and maintaining your health, then you don't need traditional doctors and drugs as much. Smaller piece of the pie for Dr. Weetman and company.

  • Reluctance to explain illness in terms of folk models of invisible germ-like agents and malevolent science: It's funny. There was this doctor back in the 1800s, named Ignaz Semmelweis. Poor Doctor S. found that the patients of midwives -- who washed their hands between delivering babies -- had far less infection and death than patients of doctors -- who didn't wash their hands between deliveries. Semmelweis was run out of town by the medical establishment and even institutionalized for daring to require that doctors disinfect their hands between deliveries. They were "reluctant" to accept Semmelweis' advice. Fast forward to the 20th century, when the medical world was sure that eating spicy food was the cause of ulcers, and patients should drink lots of milk for treatment. Barry Marshall and Robin Warren of Australia totally turned the dogma upside down with the first reports in 1983 that ulcers were caused by a bacteria, helicobacter pylori. Doctors screamed foul-- they were "reluctant" to change the way the thought about the issue. So what about all those ulcer patients who listened to their doctors and stopped eating spicy food and drank milk, and still had symptoms? Must have had somatoform disorders too, right Dr. Weetman?

Multiple Meanings and Objectivity

In his editorial, Dr. Weetman proclaims that doctors "are practising in the age of postmodern medicine. A cardinal feature of postmodernism is the derogation of objective facts which are the defining characteristic of science and the replacement of scientific certainty with the view that reality can have multiple meanings."

Dr. Weetman is just posturing here, because he doesn't HAVE scientific certainty when it comes to thyroid diagnosis and treatment. We already know that when it comes to thyroid disease, Dr. Weetman isn't even acknowledging the reality of his own specialty.

Because in thyroid disease, reality does have multiple meanings. A TSH of 4.0 HAS multiple meanings. Exactly what is scientific about THAT? And if a doctor is accepting funding, research money, free samples, patient literature, and cocktail parties from a drug company, exactly what is objective about that?

Dr. Weetman calls for doctors'

...avoidance of thyroid hormone treatment of euthyroid individuals, a robust defence of the biochemical basis for the diagnosis of hypothyroidism and institution of replacement with synthetic thyroxine as the standard, rather than Armour thyroid extract.

Maybe at some point, he will share with us exactly how he defines "euthyroid," and whether doctors should ignore clinical evidence in favor of robustly defending the lab values as the sole diagnostic tool.

And maybe by then, someone will have done some tests to clearly demonstrate why synthetic thyroxine should be standard, instead of relying on marketing literature for their arguments.

In the meantime, Dr. Weetman says, that as doctors, "...we should retain our own sense of perspective, scepticism and humility." Sounds like he should start by taking his own advice.

UPDATE!! Dr. WEETMAN RESPONDS!

Dr. Weetman read the article, and sent me the following email:

Sorry but you have missed at least one crucial point - somatoform disorders are neither hypochondriacal nor psychiatric - I make the point that future research will show that there is basis for these that currently eludes us.

I responded with the following. 

If somatoform disorders are neither hypochondriacal nor psychiatric, then much of the medical literature clearly is not in agreement with you.

Emedicine's online medical journal: "... somatoform disorders represent a psychiatric condition because the physical symptoms present in the disorder cannot be fully explained by a medical disorder, substance use, or another mental disorder. " - Emedicine

Merck Manual: "Somatoform disorder is a relatively new term for what many persons refer to as psychosomatic disorder." Merck Manual

By every definition I've seen, somatoform disorders include Somatization Disorder (which used to be called "hysteria"), Hypochondriasis, Pain Disorder, Conversion Disorder, and Body Dysmorphic Disorder. These are all psychiatric diagnoses.

Are you working off a new interpretation or definition of somatoform disorders that is a departure from the current understanding in medical literature? Because here in the U.S., somatoform disorders are diagnosed and managed by psychiatrists, and discussed in psychiatry coursework and textbooks, and somatoform disorders are sometimes considered "synonymous" with hypochondriasis.

Also, if the fact that there is some sort of basis for somatoform disorders in people who believe they have thyroid problems is relevant, it was lost in your assertion that symptoms can be disregarded in favor of tests.

You say, and I quote: "The majority of patients who demand thyroid hormone treatment for multiple symptoms, despite normal thyroid function tests, have functional somatoform disorders..."

However you choose to interpret somatoform disorders, your article completely bypasses a critical issue: If a patient demanding thyroid treatment is seeing a physician who follows the broader recommended TSH range of .5 to 5.0, and that patient's TSH falls into the 3.0 to 5.0 category, and the doctor says the thyroid tests are normal, does that patient then have functional somatoform disorders?

And if the patient goes across the hall to another doctor, who follows the narrower .3 to 3.0 normal range parameters, and with that same TSH level, the patient is told "you are hypothyroid and I recommend thyroid hormone replacement treatment," then what happened to the functional somatoform disorders diagnosis?

Before declaring all "normal" blood test patients who still believe they have a thyroid problem as having somatoform disorders, you owe it to the patient community to answer a number of critical questions:

What do you consider "normal thyroid function tests" as you discuss in your article?

Do you believe only TSH testing is needed, or do you consider T4, T3, Free T4 and Free T3 relevant to ruling out a genuine thyroid condition?

Do you follow the protocol of testing for thyroid antibodies, and treating autoimmune hypothyroidism before elevation of TSH to ward off progression of the autoimmunity and hypothyroidism?

The fact is, your article states that people who think they have a thyroid problem despite "normal thyroid function tests" have a mental health problem. As far as the patient community is concerned, we find that irresponsible and inaccurate, particularly given that you haven't even defined what is "normal" or how a physician could rule out a genuine subclinical or autoimmune thyroid condition before they moved on to the "diagnosis" of somatoform disorders.

FIND A DOCTOR WHO ISN'T LIKE WEETMAN!

And when it comes time to get your thyroid treated, take my advice, and avoid doctors like Weetman at all costs. Instead, try to find a doctor who cares about thyroid patients, understands the complexity and difficulty of diagnosis, and is willing to practice the art of medicine -- not an accountant who views you as a big-mouth with a lab test result!

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