Choosing Wisely: False reassurance to thyroid patients

False Reassurance-Choosing-Wisely

The full text of Choosing Wisely’s email reply to patients:

“Thank you for raising your concerns and sharing your personal experience. Choosing Wisely Canada and our partners, the Canadian Society of Endocrinology and Metabolism (CSEM) are not recommending to eliminate T3 testing. Choosing Wisely Canada is a national, clinician-led campaign focused on reducing unnecessary tests and treatments that offer no clinical value to patients and can cause harm. The recommendation in question, like all of our recommendations, encourages patients and physicians to have thoughtful conversations about their care which are informed by scientific evidence. Whether something is necessary or not is for doctors and patients to discuss on case by case basis, and we encourage you to share your concerns with your physician or health care provider.

We have received a large number of concerns similar to yours in the recent weeks, and have brought these to the attention of the Canadian Society of Endocrinology and Metabolism (CSEM), which developed the recommendation based on a review of the scientific evidence. CSEM recognizes and values the importance of the patient’s perspective in clinical encounters. CSEM supports an evidence-based approach to thyroid disease testing and management, and encourages endocrinologists and patients to engage in conversations about evidenced-based tests and treatments. CSEM is working on a detailed position statement regarding evidence-based thyroid disease testing and management. The statement will be made available on its website as soon as it is finalized. We will share this with you when the statement is available.

Thank you,

Choosing Wisely Canada”

Our analysis

They offer false reassurance. They employ half-truths.

They use euphemistic language like “conversation” and “evidence-based.”

Their aim is to take the wind out of our sails. They feel annoyed and want to protect their reputations.

However, well-educated thyroid patients are not so easily fooled.

We understand the practical implications of this campaign to limit Free T3 testing. We know it is meant to protect and enforce the TSH paradigm and T4 monotherapy.

Having a “conversation” about “evidence-based” medicine really means that the medical authorities will use their power to “enforce” what is actually “evidence-limited” medicine and “consensus-based” medicine.

We know that endocrinologists recommend gathering Free T3 evidence only in limited circumstances:

  1. When pituitary TSH is suppressed or not secreted at all — as in central hypothyroidism and in hyperthyroidism
  2. Whenever doctors struggle to “normalize” the TSH.

Only if TSH exceeds the laboratory reference range by an arbitrary amount, or falls below reference, will they recommend the testing of Free T4, and possibly also Free T3.

But they will NOT recommend T4 and T3 testing in maintenance therapy for the millions of patients who have primary hypothyroidism from various causes (autoimmune thyroid disease, post-thyroidectomy, or post-ablative therapy for hyperthyroidism).

This is because T4 hormone therapy is so powerful at normalizing pituitary secretion of TSH in the vast majority of patients. Unfortunately, they spread the false reassurance that normalizing pituitary TSH optimizes thyroid hormone levels.

Evidence from research that actually measures T3 and T4 in thyroid therapy has shown that a significant percentage of thyroid patients on standard T4 monotherapy cannot achieve more than mid-range Free T3 values along with a normalized TSH or even a suppressed TSH. (Midgley et al, 2015, Endocrine Connections, “Variation in the biochemical response to l-thyroxine therapy”)

In effect, conventional thyroid therapy has the power to deny patients access to optimal Free T3 levels.

Free T3 evidence poses a threat to the current medical establishment. They choose to focus on the threat of financial expenditure by health care systems. But there’s a deeper threat to the field of endocrinology —

Free T3 evidence threatens the supremacy of T4 monotherapy and the dominance of TSH-only testing.

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