2012 ATA thyroid guidelines ask for clinicians’ independent judgment

In recent years, Canadian and other international thyroid guidelines have enacted local policies that restrict thyroid therapy and testing, often citing the American Thyroid Association (ATA) & American Association of Clinical Endocrinologists’ (AACE) guidelines in 2012.

What most “guideline policers” fail to notice is that the 2012 ATA-AACE’s guidelines begin with a disclaimer against their misuse as laws.

The disclaimer offers a lot of freedom to doctors in treating patients!

• They openly claim that they are not establishing a “standard of care” and cannot guarantee outcomes,
• They express humility about the ability for any guidelines to cover all clinical situations with every individual patient, and
• They admit the ongoing nature of research review and shifting consensus regarding guidelines, admitting that because research is ongoing, the guidelines are a “working document” and future updates and revisions are expected,
• They respect the necessity of doctors exercising their evidence-based discernment and independent judgment, even while they are informed by the guidelines.
• They hope for voluntary adherence, but do not demand it.

Let’s meditate on their disclaimer from their Introduction section, shall we?

The disclaimer

“The ATA develops CPGs to provide guidance and recommendations for particular practice areas concerning thyroid disease, including thyroid cancer.

The guidelines are not inclusive of all proper approaches or methods, or exclusive of others.

The guidelines do not establish a standard of care, and specific outcomes are not guaranteed.

Treatment decisions must be made based on the independent judgment of health care providers and each patient’s individual circumstances.

A guideline is not intended to take the place of physician judgment in diagnosing and treatment of particular patients (for detailed information regarding ATA guidelines, see the Supplementary Data, available online at www.liebertpub.com/thy).

The AACE Medical Guidelines for Clinical Practice are systematically developed statements to assist health care professionals in medical decision making for specific clinical conditions.

Most of their content is based on literature reviews.

In areas of uncertainty, professional judgment is applied (for detailed information regarding AACE guidelines, see the Supplementary Data).

These guidelines are a document that reflects the current state of the field and are intended to provide a working document for guideline updates since rapid changes in this field are expected in the future.

We encourage medical professionals to use this information in conjunction with their best clinical judgment.

The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.”

Voluntary adherence

In the “Supplementary Data” file linked to the 2012 ATA & AACE guidelines document, further disclaimer statements echoing the above appear under the general heading “American Thyroid Association Clinical Practice Guidelines.”

In addition, we have an explicit statement that adherence is voluntary:

“Therefore, the American Thyroid Association considers adherence to this guideline to be voluntary, with the ultimate determination regarding its application to be made by the treating physician and health care professionals with the full consideration of the individual patient’s clinical history and physical status.”

Endocrinologists exercise independent judgment

In the year 2013, a survey of 880 endocrinologists testing practices revealed that many of them exercised their independent judgment … by disagreeing with these restrictive guidelines (Burch et al, 2013).

Among these thyroid experts, “Persistent hypothyroid symptoms despite achieving a target TSH would prompt

• testing for other causes by 84.3% of respondents,
• a referral to primary care by 11.3%, and
• a change to l-T4 plus l-T3 therapy by 3.6%.
• Evaluation of persistent symptoms would include measurement of T3 levels by 21.9% of respondents.”

Clearly, the international experts exercise freedom to contravene guidelines by initiating LT3 therapy and ordering T3 hormone tests.

If a study were done in 2019, what would the numbers be now?

Do doctors feel free to interpret the guidelines?

Despite this overt encouragement of clinical freedom to disagree and dissent, we’re seeing more and more heavy-handed restrictions on thyroid therapy that inflate the guidelines into absolute laws.

Faith in the authoritativeness of the guidelines is blinding people to the narrowness of thyroid guidelines. They are so restrictive that they could never fit all patients.

That’s what my next post will be about… the way in which doctors’ independent judgment in thyroid therapy is being repressed and punished.

People are misusing the guidelines to bully doctors into conformity.

Doctors, you don’t have to submit to guideline-bullies.

You can exercise your clinical judgment.

• Tania S. Smith

REFERENCES

Burch, H. B., Burman, K. D., Cooper, D. S., & Hennessey, J. V. (2014). A 2013 survey of clinical practice patterns in the management of primary hypothyroidism. The Journal of Clinical Endocrinology and Metabolism, 99(6), 2077–2085. https://doi.org/10.1210/jc.2014-1046

Garber, J. R., Cobin, R. H., Gharib, H., Hennessey, J. V., Klein, I. L., Mechanick, J. I., … Woeber, K. A. (2012). Clinical practice guidelines for hypothyroidism in adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine Practice, 18(6), 988–1028. https://doi.org/10.4158/EP12280.GL