The more experience I have with being a patient with two chronic diseases, the more the medical profession baffles me.
Today I logged in to Facebook only to see numerous posts concerning a new publication by the American Thyroid Association titled “Guidelines for Treatment of Hypothyroidism”. I’ll provide a brief overview. A committee was formed to review Levothyroxine (T4) and its effectiveness in treating hypothyroidism.
Levothyroxine (T4) has long been embraced as the “gold standard” for treatment of hypothyroidism and is “effective in most patients, but some individuals do not regain optimal health on T4”. Yet the study concludes “that levothyroxine should remain the standard of care for treating hypothyroidism, noting that no consistently strong evidence supports the superiority of alternative therapies.” No consistently strong evidence? All one has to do is go to social media to see the photos and read the personal accounts of how levothyroxine failed certain patients. Their stories are all the same – “this is what I looked like, this is me now; these were my symptoms, those symptoms are gone.” So, my question is why do we remain with one (1) drug recommendation in the standard of care.
Pharmaceutical companies produce thousands of medications and we have the choice of one. Cancer doesn’t – there are numerous drugs used for each form of cancer. Heart disease doesn’t, high blood pressure doesn’t, cholesterol doesn’t – there are numerous drugs used. I could go on, but you get the point. Those patients are not forced into taking one (1) drug whether it works effectively or not, they (the patient and medical team) are given choices to find the best one to address that specific disease. But – it doesn’t stop with simply the recommendation of one medication.
The committee states that patients who suffer from continuing thyroid symptoms, but have TSH in the reference range while on Levothyroxine should to be referred for mental health evaluation. So let me use my analytical skills – the medication for my thyroid condition is not helping the symptoms of the disease and I feel terrible and instead of reassessing the medication, I could be sent for a psych evaluation? This is not, repeat not, a mental health issue — it is an issue of my physician evaluating my symptoms and recommending the best medication. That means not a selection of only one (1) medication when others are available and may work more effectively.
I am confused and angered by the committee’s position that their guidelines claim that medical ethics prohibit prescribing drugs that are “inferior to the standard of care” and that patients who request “inappropriate therapies” do not have “full decision-making capacity.” They believe that while physicians are “taught that patient autonomy means they should cater to patient preferences”, yet if “patients are requesting inappropriate therapies this is a misinterpretation.” And their recommendation would then be to “protect patients who do not have full decision-making capacity – they must demonstrate understanding, appreciation, rationality and expression of a choice and voluntariness, in which there is no coercion.”
What this actually states and how it is being interpreted are interesting, almost laughable. As a patient I have to demonstrate understanding, rationality and a voluntary expression of choice and yet when I do and it is not the one (1) drug they recommend then I am not capable of decision making and basically the physician at that point will coerce me to accept the one (1) drug they have designated as the standard.
Physicians on the other hand are also being held captive to this publication. The guidelines warn that physicians who prescribe “substandard, unsound or untested medical procedures or therapies”, such as T3/NDT, could face “legal consequence or licensure revocation, as these ethical violations constitute medical negligence.” Oh, is that a threat?
So here are my thoughts and this is relative to any disease and treatment, not just hypothyroidism.
Why do medical professionals refuse to listen to patients and treat the symptoms as the patient describes them? Why are patients not believed?
If a patient is on a drug and labs are within acceptable ranges, BUT the patient still does not feel well, why would the first line of response by physicians be “send for a mental health evaluation.” I am not crazy, I AM SICK ! Perhaps we should consider that the drug is not working effectively on this patient and look for another course of treatment, which could include a drug.
If a physician or task force wants to discuss my “full decision-making capability” – don’t be a coward and hide behind a few pieces of paper, call me and let’s discuss this face-to-face. Are you going to sit across the table from me and tell me that I don’t understand and cannot make the best decisions for MY health?
I battled unexplained symptoms for several years prior to my diagnosis of rheumatoid disease. I learned to read, and read, and read and look up definitions until I had a good understanding. Do not tell me I am not capable of making a decision for my life. It’s my life. I was reading and researching and learning while the medical community completely dismissed my symptoms – until the day I was knocked on my bum and couldn’t get out of a chair and then diagnosed with rheumatoid disease.
And we end the guideline publication by making a reference that physicians, if they don’t go along with the information presented, could face legal consequence or licensure revocation. Seriously? If these guidelines are so compelling why do you have to threaten the physicians?
I could bring up the concern for conflict of interest. What association would recommend one (1) drug only when others are available? Does the association or any of the professionals involved in the study stand to gain any benefit by singling out Levothyroxine and promoting only that one (1) drug? Do the drug companies who manufacture Levothyroxine provide financial support in form of funds to sponsor meetings for the association? Do the drug companies provide funds for grants for the physicians? It makes one wonder.
These guidelines are nothing more than coercion. They force the patient to accept one drug of the committee’s choice and suggest that if I complain about continued symptoms I should be sent for a mental health evaluation. I do not want to be controlled in my health care nor do I want fear to permeate the decisions made by my physician.
If you truly want to “contribute to your ability to improve the lives of your patients with hypothyroidism” –
1. Listen to your patients.
2. Take their comments seriously.
3. Utilize any and all available medications for treatment depending on what works best for the patient and what the patient wants.
4. Partner with your patient. Respect their opinion.
5. Include patient engagement/patient activists in these guidelines.