Article on Management of Thyroid Dysfunction

[gimel]

I ran across this article written by a joint panel from the AACE, ATA and the Endocrine Society.  I thought some of our members would find it to be worthwhile background material for trying to understand the obstacles we encounter at our doctor's office.  To me it is clear that they are ultra conservative on deciding on when and how to treat a patient. This is of course what we have to contend with every day.  

http://jcem.endojournals.org/cgi/content/full/90/1/581?ijkey=9cefd7e1f8b571ef7b5ea3ff13bb5faf63ba783a&keytype2=tf_ipsecsha

To me, the most valuable bit of info in the article was this.  "The critical issue, therefore, is that data-based treatment guidelines in areas where those data are insufficient should not be stated in a way that might be considered restrictive, but should, instead, allow providers the flexibility to use the sound clinical judgment that they, having knowledge of each patient’s individual circumstances, are the most qualified to render."

As I interpret this,  physician judgment and treating a patient clinically is paramount and should over-ride data-based treatment guidelines.  Somehow I think this got left out of the doctors' training manual.  LOL  I always thought maybe the reluctance to treat any patient whose test results fell within the so-called "normal" ranges, was due to a fear of going outside the guidelines and being subject to peer review and censure.  Or being fearful of malpractice lawsuits.  Or being beholden to big pharmaceutical companies, who spread a lot of money throughout the system.  To me, the above quote may be a way for patients to try to persuade their doctors that clinical treatment for symptoms has been recognized and endorsed by the AACE, ATA and ES.

What do members think?

[SassySharon]

haha...I love it!! But I thought of a few......

AcceptaNCE of inferior medical treatment.

FreelaNCE  doctors who are not committed to a patient for an extended amount of time...come and go as they please!!

RefereNCE..ranges that change from lab to lab...

Thanks for sharing         -sass-

[gimel]

Thanks for you time and comment.  As I have thought about the widespread misdiagnosis and improper treatment, I have come to realize that it is an NCE problem.  

IgnoraNCE of the fact that TSH is inadequate as a sole diagnostic and that symptoms and FT3 and FT4 should be higher priority, to facilitate clinical treatment.

ArrogaNCE that prevents consideration that current practices might be wrong and then spending time to broaden knowledge base.

ReluctaNCE on the part of patients to question their doctor's diagnosis and treatment and then push for development of a better plan.

InterfereNCE in testing by the insurance companies trying to hold down cost, without realizing that overall costs would be much lower if the diagnosis and treatment were effective from the start.

InflueNCE of the big pharmaceutical companies in maintaining status quo through their funding of University research, Professional Medical Organizations, etc, all with an eye to  profits.

So you can see why I definitely think it is an NCE problem,  LOL  Did I overlook anybody?


          ___

[SassySharon]

Just wanted to add a note:  I just got off the phone with my Regular MD office.  I had called to see if they would draw my labs at their office instead of driving the 150 mile round trip to my endo office to draw his requested labs he wants done this week.  The lab tech asked me which labs he had requested.  I told her the TSH and T4,Free and possibly the T-3,Free.  She then asked me which Insurance company I have. After I told her, she said she could draw them for me and that  she had asked about my insurance because "most Insurances will NOT pay for the FT4 or FT3's, just the TSH. That is why we routinely just do TSH "    and my insurance does pay for them.

gimel, this brings more light  to me the importance concerning this paragraph that you addressed: Again I thank you for putting this out there.

"The critical issue, therefore, is that data-based treatment guidelines in areas where those data are insufficient should not be stated in a way that might be considered restrictive, but should, instead, allow providers the flexibility to use the sound clinical judgment that they, having knowledge of each patient’s individual circumstances, are the most qualified to render."  

I would like to know others thoughts on this issue!  Are we not being tested and treated because of this?

( I have to make the trip anyway though because she offered me a time of March 23rd.  Ha I need them ran THIS week.. not sure what is up with that, because she was just drawing and sending to the same lab my endo uses.     -sass-

[SassySharon]

Well!! I just finished reading this article and found it to be most eye-opening!!  It makes me wonder who is leading this cosensus panel and why they would possibly believe that routine testing for thryroid conditions should be limited.  Especially when the findings of these diseases could considerbly lend earlier treatment for those possibly with diabetes, pregnant women with hypothyrodism, hashimoto's, and many other diseases.  These deliberations should be in the betterment of the welfare towards  these conditions, not limitations.  Not to say anything about the thousands of us that suffer the debilitating symptoms of thyroidism.  If Iand my son had be routinely tested at an earlier date we may still have an active thyroid gland.  Me and my mother-in-law's pituitary tumors may have been found earlier..My mother-in-law would not have lost her eye sight due to her Pituitary tumor rupture.  Young men and women would not be spending thousands upon thousands trying to treat infertility issues.  Instead they would be parents.

Subclinical hyperthyroidism is defined as low serum TSH levels associated with normal free T4 and free T3 levels.    Why would they want to prevent these routine and early tests? Is it because that it would effect the individual agencies, health maintenance organizations, and the Center for Medicare and Medicaid Services who often use published guidelines to limit reimbursement for both testing and therapy?? As well as the Insurance agencies.  Who again are on these panels??

So when our primary-care physicians, physician assistants, and nurse practitioners  use guidelines as a care tool, under the assumption that they are the best distillation of advice from research and experts in the field, they could be actually being misled.  Our health depends on these findings.  

In the statement I copied below of this article, I would hope our praticioners will be allowed to treat their patients instead of having inappropriate guidelines treating us.
  "In our view as both practicing and academic endocrinologists, the potential benefits of early detection and treatment of subclinical thyroid dysfunction significantly outweigh the potential side-effects that could result from early diagnosis and therapy. Because the potential harm of early detection and treatment appears to be so minor and preventable, it seems prudent to err on the side of early detection and treatment until there are sufficient data to definitively address these issues."

Thank You for bringing this article to our attention.  I have learned some of the significance of the reasons of why our doctors may not be treating their patients but being conservative instead of proactive. With the publication of this article maybe their hands will be untied.
Sass