Professor A.P. Weetman’s recent article in Medscape and Clinical Endocrinology

Doctor Barry Durrant-Peatfield’s response:

In his article mysteriously entitled, ‘Whose thyroid replcement is it anyway’ – Professor Weetman starts the discussion by taking the view that there seems nothing more straightforward than the treatment of hypothyroidism;. One certainly wishes that this simplistic view were true. Sadly, this is very far indeed from the case. Thyroid deficiency affects every organ, every tissue, every cell of the body, and in any degree from a mild dysfunction to complete failure; moreover, being human necessarily implies that sufferers are going to react differently. This makes, on the contrary, for very great complexity in the management of hypothyroid dysfunction.

It would be a great help if present assays, however robust, could be relied upon; but they cannot. The gold standard of measurement, the TSH, is subject to extreme error. The tissue thyroid receptors, the alpha 1 and 2 receptors and the beta 1 and 2 receptors provoke a differing TSH response to cellular thyroid hormone deficiency; and a pituitary, affected by a period of hypometabolism, will have a dysfunctional response so that its TSH production may be down-regulated. The measurements of serum thyroxine and serum liothyronine levels are similarly full of hazard. They are, as it were, a snapshot of blood levels, which may have a very limited relationship to the amount of T3 binding to tissue receptors, or the viability of T4 to T3 conversion, or indeed the availability of T4 from the transport protein. One reliable way of overcoming these problems is the assay of T3 and T4 excreted over 24 hours in the urine, a technique described by Baisier and Hertoghe; but, almost unbelievably, endocrinologists, if they are aware of this assay, unite in condemnation of it.

Nowhere has Prof Weetman given any credence to the clinical appraisal of the hypothyroid state. A proper history and physical examination can make the diagnosis obvious to the physician. We have the examples of Murray and Hertoghe in the first two decades of the last century, whose descriptions of their clinical approach are without peer; and are just as true today as they were then.

In this world of evidence based medicine this has come to mean that the evidence is narrowed down to clinical assays only. It should go without dispute that the physicians’ observation should not only be included in this evidence, but, indeed, have precedence over the tests. In this connection the Barnes Basal temperature test does not deserve the implied opprobrium heaped on it by Prof Weetman. It is a most valuable tool as a screening test, and Prof Weetman misunderstands its role when he suggests that it is used to make the diagnosis. In fact a low basal temperature points the way to a fuller clinical appraisal, and it is here that its great value lies.

The dissatisfaction of patients as described in the listed submissions is clearly extreme. Indeed, it is difficult to find a parallel anywhere else in medicine. There are really only two possible explanations for the anger and depth of feeling thus expressed.

That there are disaffected pressure groups intent on torpedoing the proper practice of medicine for an agenda of their own.

That the standard of care, diagnosis and treatment offered by practitioners falls so far short of reasonably expected standards that desperate patients want something done.

Prof Weetman clearly discounts the second alternative, refusing to countenance the possibility that the conduct of himself and his like minded colleagues could possibly be at fault. Patients who have the temerity to conduct their own research and so question the rigidly held conclusions of their medical advisors are, it would seem, straying into fields of knowledge they have no right to go. In fact, these disaffected, and, be it said, ungrateful folk, are quite as bright as many of the doctors, and can work things out for themselves, successfully and correctly too. It is the fact that they do so which offends Prof Weetman’s sensibilities. These are matters, he feels, for only the informed and elected cognoscenti; not for the vox populi. It would perhaps be disingenuous to point out that one of the most serious, and least considered, complications of thyroid illness is consequent adrenal dysfunction, which explains why so many patients stubbornly refuse to admit they are cured when the blood tests say they are.

This brings us to the quite outrageous and sweeping assertion that the majority of these patients have functional somatoform disorders. This fine new description, thanks to Prof Weetman’s efforts, is a neologism for hysteria. It implies that this majority of patients have personality disorders which make it impossible for them to accept, with good (and uncomplaining) grace, their illness. While no illness in medicine can ever be entirely without this pathology, this sweeping assertion is very much open to question. Indeed, one could be forgiven for wondering, perhaps, if these are the patients who haven’t played the game by the rules, and so remain ill, and it brings the whole of Prof Weetman’s argument into a reductio ad absurdum.

No wonder we on the inside, cannot adequately describe these somatoform disorders. Could it be, it must be asked, that on the contrary, these patients really are ill?

We are also asked to accept that healthism is a modern evil. The disgraceful fact, it would seem, is that the mob, distrustful of their doctors and a multiplicity of new and more lethal drugs, is actually out to improve its own health. This, of course, is the new curse of the age which should be stamped out by Prof Weetman and his colleagues. The manifest absurdity of this view is beyond comment.

Perhaps it should be made clear why this flood of angry and disaffected patients seek out knowledge about their illness. Taking on board, for the sake of arguments, that a) they really are ill, b) they have through their researches learnt about their illness, and c) know the broad outlines of their treatment, if whatever they say is ignored, or put down to a functional somatoform disorder, then would not this response to their fate be entirely expected?

Broda Barnes, whose pioneering and carefully researched work receives a passing mention in Prof Weetman’s article was of the opinion that perhaps 30% of folk by mid-life may have some level of thyroid dysfunction. The present writer who can lay claim to more than 40 years of practical experience with hypothyroidism and hypoadrenalism, sees no reason to disagree with this admittedly alarming statistic. Yet Prof Weetman would have us believe that the majority of such sufferers are, basically, making the whole thing up. They cannot really be ill because the standard evidence gives them no support, and because they are told they are not. It is no help asking either, it would seem. They won’t be listened to, and they won’t be answered.

The new guidelines suggesting that patients should not be treated unless the TSH is over 10, is not only totally out of step with thinking elsewhere in the world – and especially the American Association of Clinical Endocrinologists – but is actually bizarre. There is a reference to the risks of a suppressed TSH, which are very much more imagined than real. What these new guidelines suggests, will condemn, certainly, thousands of patients to being refused treatment; and their consequent illness the result of their functional somatoform disorder. Already, these guidelines have elicited a storm of protest, and it is to be deeply regretted that Prof Weetman allies himself to this position. Quite what the agenda is that condemns so many patients to perhaps decades of ill-health, can only be wondered at. Worse, guidelines have a way of being set in stone, and then doctors who think outside the envelopes, will find themselves proceeded against, led perhaps by Prof Weetman himself.

As we know, hypothyroidism may be manifest by a large number of symptoms and signs; and it may be instructive to pick out certain of them. We can include weight gain, depression and anxiety, arthralgia and rheumatic illness, and raised cholesterol. If the diagnosis of hypothyroidism is discounted even forbidden then functional somatoform disorders must receive attention, and the caring practitioner, anxious to help, may find himself prescribing antidepressants, non-steroidal anti-inflammatories, statins, and weight loss agents. The disadvantages of this approach lie in the cumulative expense and multiplicity of side effects, apart from the fact that it is symptoms being dealt with and not cause.

Should the practitioner be able to overcome the hurdle of the diagnosis, then all the symptoms and signs could be treated using thyroxine, for a few pounds a month and usually with great success.

There are certain precepts in medicine to which attention should be drawn with which perhaps Prof Weetman is no longer familiar. The first is to remember the value of Occam’s razor in medicine: that is, common things commonly occur. Then the importance of listening to the patient: 9 times out of 10 they will tell you the diagnosis and often the treatment. Finally: if the lab tests don’t match your clinical intuition, back your intuition. Armed with these simple but valuable precepts, the diagnosis of functional somatoform disorder can be relegated to where it belongs, and the correct and perhaps obvious diagnosis made.

The great fear is that the example of Prof Weetman and the guidelines suggested by him (and recently in other quarters) will become establishment medicine, and doctors will not dare to make the correct diagnosis. To do so may be more than their career is worth. Only a handful of independent, and independent minded, practitioners, will be prepared to shoulder this risk on behalf of their patients. And their number diminishes steadily.

So one must ask what is it all about? Recently we learned that osteopaths and chiropractors don’t help us in the way we all believe; that omega-3 supplements are no help to our cardiovascular health and that we should cheerfully accept very large doses of statins; and now that hypothyroidism is actually quite rare and its diagnosis likely to be evidence of a doctor’s incompetence in the face of pressure from his patients.