How thyroid guidelines are being used to punish doctors

Clinical guidelines are supposed to promote patient health and encourage evidence-based medicine and physician discernment, but thyroid guidelines aim to restrict testing, restrict medication, and prevent any change in therapy practices.

Indeed, the enforcement of restrictions appears to be the main purpose of local and international thyroid therapy guidelines today.

These thyroid therapy guidelines, and national guidelines that derive from them like those in the UK by the British Thyroid Association (BTA), are being used oppressively and punitively against clinicians by medical peers who police their application.

Guidelines as persuasive vs. obligatory

John Midgley has written this in a 2019 article in BMC Endocrine Disorders:

It appears that what we are witnessing constitutes an unprecedented historic change in the diagnosis and treatment of thyroid disease, driven by over-reliance on
a single laboratory parameter TSH and supported by persuasive guidelines.

[…]

In a rapidly changing medical environment, guidelines have emerged as a novel though often over-promoted driver of unprecedented influence and change.

Treatment choices no longer rest primarily on the personal interaction between patient and doctor but have become a mass commodity, based on the increasing
use of guidelines not as advisory but obligatory for result interpretation and subsequent treatment.

Doctors are being hoodwinked by these changes.

Doctors must awaken to the way their professional judgment and intelligence is being eroded by the misuse of guidelines as professional laws.

Patients call on doctors to stand up

Thankfully, the 2012 ATA and AACE guidelines have written a beautiful, humble disclaimer at the opening of their guidelines.

They have expressly stated that

• physician adherence is voluntary,
• clinicians must exercise independent judgment, and that
• individual patient cases may be exceptions to the routine.

However, readers of the guidelines too often skip over this introduction, skip over the detailed discussions, and make a beeline toward the numbered statements that summarize recommendations.

In contrast with this disclaimer and all the pages filled with their persuasive reasoning, the summary recommendations are worded very briefly, strongly and heavy-handedly.

Doctors, you should judiciously choose not to follow certain thyroid guidelines if your thyroid patient’s case requires it, as long as you perform due medical diligence.

We, your thyroid patients, need you to be strong and confident for our sake and to stand up for the quality of your training, experience, and discernment.

All thyroid patients who suffer under the narrowness of guidelines rely on your moral courage and your intelligence.

But you must be prepared to back up your decisions with careful documentation, good logical and biological reasoning, and authoritative research publications.

Everything you do just has to be done as if you were standing before a tribunal of your peers, because if you care enough for your patients to gain a reputation, you just might be dragged to the medical council or college by some envious peers.

Thyroid guidelines in medical tribunals

In professional trials against thyroid doctors, non-compliance with policies and guidelines has been cited as one of the major reasons for punishing them with thyroid prescribing license suspensions and thyroid clinic closures.

In Canada in 2019, Ron Matsusaki’s thyroid clinic in Digby, Nova Scotia was closed because of a practice of ordering thyroid hormone tests and prescribing thyroid hormones beyond levothyroxine, and the province’s College of Physicians and Surgeons has placed thyroid-prescribing restrictions on his license. Read our original post on the clinic’s closure.

But I’d like to get into some depth on another doctor’s case that was more publicly announced.

A September 2019 news article by Clare Dyer on the British Medical Journal website described the suspension of a London, UK doctor repeatedly referred to non-adherence to guidelines:

• Dr. Georges Mouton “’persistently overdiagnosed thyroid problems‘ and treated patients with drugs that were not clinically indicated.”
• “The General Medical Council’s allegations against Mouton accused him of ordering unnecessary or unproved tests…” “Wrongly interpreting the test results as evidence of thyroid problems, sometimes without considering obvious alternative diagnoses, Mouton … proceeded to treat patients in ways that contravened guidelines, the GMC alleged.”
• “His treatment strayed from common UK thyroid disease guidelines in many respects”
• “He prescribed combined T3 and T4 thyroid hormone treatment to a patient whose thyroid function was biochemically normal. He also prescribed iodine, an unsafe supplement for patients with thyroid problems, and prescribed thyroid hormones to a child, when guidelines said that this should be done only by a consultant paediatric endocrinologist.”
• “Charles Thomas, chairing the medical practitioners tribunal, said that Mouton had ignored blood tests that showed normal thyroid function, continuing to treat patients with thyroid hormone and selenium, which in these circumstances could cause harm but no benefit.”

Granted, it is impossible to know for sure whether indeed Mouton’s decisions were, as the GMC stated, “not clinically indicated” for the individual patients. Individual patient histories and clinical presentation could not be provided with the news report.

But it is crystal clear from reading the news article that the BMJ news reporter, Clare Dyer, made as many efforts as possible to defame the doctor who was being accused of guideline-nonconformity among other things. Dyer disparaged his philosophy of Functional Medicine and its role in the medical landscape (something very easy to do nowadays), despite the fact that he had earned his MD in 1983 and had been licensed by the General Medical Council to practice in the UK since the year 2000.

Dyer presented only accusatory and derogatory statements and details, even though there was considerable debate at the hearing. “Six medical experts testified, two on the GMC’s behalf and four for Mouton.” We do not know to what degree the sanctions were reduced by the successful appeals of the four experts testifying on Mouton’s behalf.

Misreading of thyroid guidelines as laws

Regardless of whether or not Mouton is indeed guilty of professional misconduct, major or minor, the most troubling aspect of this trial is that the tribunal appeared to treat thyroid guidelines as absolute truths and laws.

Turning the guidelines into an ax to chop off a doctor’s head, or even just his ear, sends a frightening message to all other thyroid doctors.

It has huge ripple effects worldwide for thyroid patients as well.

The British Thyroid Association’s (BTA) guidelines were cited in this case (Okosieme et al, 2015).

Many positions and recommendations made in the 2012 ATA guidelines are echoed in the BTA’s UK thyroid guidelines.

Even a lack of close reading of ATA guidelines shows through this article about the accusations and sanctions against Dr. Mouton.

For example, it is taken without question that iodine supplementation is intrinsically “an unsafe supplement for patients with thyroid problems” and that selenium will “cause harm and no benefit.” However,

• The 2012 ATA guidelines allow for exceptions on iodine therapy. Iodine supplementation is not recommended in iodine-sufficient regions “unless iodine deficiency is strongly suspected and confirmed.” Leung and Braverman, 2012, explain that iodine risk occurs mainly in “susceptible individuals with predisposing risk factors.” Such risk factors can be excluded in patients before iodine supplementation begins. Both iodine excess and deficiency must be prevented. Global migration and changes in diet and consumption of non-iodized salt makes it doubtful whether an entire “region” can be classified with a single iodine status.
• The 2012 ATA guidelines admitted that “Selenium has notable theoretical potential for salutary effects on hypothyroidism and thyroid autoimmunity including Graves’ eye disease, both as a preventive measure and as a treatment. However, there are simply not enough outcome data to suggest a role at the present time for routine selenium use to prevent or treat hypothyroidism in any population.” An ATA recommendation against “routine” use of selenium does not translate to a blanket prohibition or a statement that selenium can cause “harm but no benefit.”
• Recent research proves clinical benefit of both iodine and selenium as long as excess is avoided: Rayman, 2019 writes ” There is evidence from observational studies and randomised controlled trials that selenium, probably as selenoproteins, can reduce TPO-antibody concentration, hypothyroidism and postpartum thyroiditis.” “Appropriate status of iodine, iron and selenium is crucial to thyroid health.”

The ATA’s sentiment against “routine” use of iodine and other supplementation is echoed in the 2015 UK guidelines. What does the word “routine” mean? Read the guidelines carefully. They do not forbid cautionary, careful, non-routine and non-excessive use. Look at the logic of their rationales. Look also at their citations.

Do guidelines prohibit testing?

According to this medical tribunal chair Charles Thomas, even thyroid testing guidelines had to be followed not just to the letter, but to the spirit. Doctors must conform to the TSH-centric, T3-blind paradigm underlying the guidelines.

The 2012 ATA thyroid guidelines include a section on the problems with overreliance on TSH. They then go on to over-rely on the Low-TSH-risk research tradition that has chronically ignored patients’ diverse Free T3 levels on therapy.

In this document, the ATA makes prohibitions against diagnosing thyroid disease based on Free T3 prior to therapy, and it’s logical because prior to therapy, the body does everything it can to maintain FT3 within reference range even after FT4 falls below it.

But in cases where hypothyroidism is already properly diagnosed and therapy is initiated, ATA guidelines do not forbid FT3 and FT4 testing. Look for it. It’s not there. Nope.

Even the ATA and BTA UK guidelines’ brief dismissal of FT3 hormone tests rests on thin grounds and naive claims of ignorance of decades of research on the physiological harms of low T3, reduced T3 within reference range, and low T3:T4 ratios.

But the mere ordering of tests is subject to incredible scrutiny nowadays.

Ordering a test deemed “unnecessary” by the guideline gurus is now being turned into a shameful revelation of naivety, almost equivalent to confessing that you believe the earth is flat.

You’re being shamed into not looking at the dirty evidence that has been swept under the normal-TSH rug.

Come on, T3 is the most powerful thyroid hormone. Of course the human body cares how much of it is available in circulation, and researchers openly admit this in scientific publications.

There’s a guilty reason why guidelines don’t want you to test it during therapy. Standard thyroid therapy puts our FT3 at risk of depletion, and no amount of extra FT4 in blood can make up for its loss. We lose T3 if our thyroid metabolism is all topsy-turvy because we’re chronically or critically ill, and we lose T3 if we aren’t equipped for efficient T4-T3 conversion.

It appears from the use of guidelines that no clinician must ever order medical tests deemed “unnecessary” by the tribunal, not even genetic tests for DIO2 or DIO1 polymorphisms that can prove we’re genetically handicapped to convert thyroid hormone.

In addition, doctors must always interpret tests in rigid ways as guided by the most simplistic summaries of the guidelines.

The “overdiagnosis” fallacy

We see by Dyer’s quotations that punishment of Dr. Mouton is supposedly meant to defend patients and caution doctors against “overdiagnosis.”

Think about how ridiculous this proposition is.

Overdiagnosis is a serious crime only to penny-pinching efficiency gurus who want to imply that fragile-minded patients are being terrorized by knowing their test results and thereby “harmed” by evidence and its possible alternative diagnoses.

Overdiagnosis is an opinion.

It’s an accusation expressed by someone who disagrees with your diagnosis, someone who might not have all the clinical evidence or your reading in thyroid scientific literature.

Overdiagnosis, even when it is mistaken, does not necessarily lead to overtreatment.

Nor does a tribunal’s act of accusing a doctor of “overdiagnosis of thyroid problems” prevent the worse and more rampant medical failures of

• underdiagnosis,
• undertreatment,
• misdiagnosis, and
• mistreatment

which can all occur within the TSH, FT3 and FT4 reference ranges that are far too wide even for a healthy individual.

Neither the word “unnecessary” (in regard to tests) nor the word “overdiagnosis” appear in the 2012 ATA guidelines or the 2015 BTA UK thyroid guidelines, but they do appear in the quoted words of the tribunal in this news report about Dr. Mouton’s sanctions.

Where is this language and philosophy coming from?

Aha.

“Overdiagnosis” is a word you will find discussed at length in the BMJ’s polemical essays on medical economy and efficiency, and discussed in one obscure document on the GMC website. Go search and see.

It appears that this economizing movement in health care is a “bee in the bonnet” of local administrators. It has also inspired local endocrinologists who want to curry favor with bean-counters and climb the career ladder by stepping on the heads of their peers, accusing other doctors of ordering un-recommended tests.

These trends in health care today are simply taking advantage of restrictive testing philosophies in thyroid guidelines.

These trend-followers never question the basis on which guidelines dismiss most other tests beyond the TSH.

They certainly never question whether the patient herself has a right to investigate and resolve chronic health problems that limited, consensus-based guidelines currently dismiss and ignore.

What happened to independent clinical judgment?

It appears that this sad state of affairs is being driven by several unprofessional desires:

• The desire to police and enforce thyroid conformity among doctors, based on an unreasonable belief that thyroid therapy, unlike other diseases, ought to be an area of absolute consensus. What? Is therapy for other chronic, systemic organ-failure diseases like type 1 diabetes as closed to debate, and as restrictive and punitively policed in this manner?
• The desire to defend standard levothyroxine monotherapy against all its pharmaceutical competitors. Ponder the fact that biochemists say all thyroid hormone medications offer equally bioidentical hormones, and history proves that they can all render hypothyroid persons euthyroid, but clinical experience proves not all of them will work equally well for each patient. This narrow defense of one hormone’s use in therapy is as ridiculous as mandating only one type of insulin (such as synthetic slow-release) in diabetes therapy.
• The desire to repress, dismiss, and deny thyroid patients’ complaints about standard thyroid therapy. Patients can be annoying and puzzling because following the current guidelines leads to poorly optimized therapy and numerous health problems. Guidelines help doctors rationalize genuine complaints by blaming them on other health conditions (misdiagnosis).
• The desire to consider patients who pay for alternative thyroid therapy as victims of greedy renegade doctors. This deflects attention from the fact that thyroid patients are often driven to seek out alternative practitioners at the borders of medical conformity only after they have first become the victims of doctors who blindly follow restrictive thyroid guidelines.
• The desire to remove patient-pay options for thyroid testing and therapy by finding faults with and punishing functional medicine practitioners who charge patients a fee and therefore can take the extra time and effort to investigate their cases. This is a way of indirectly punishing, repressing, and controlling all of their patients who can afford to have such freedom and agency in their therapy.
• An efficiency- and economy-driven medical value system that aims to prevent thyroid therapy from becoming more complex and costly than one test (TSH) and one medication (LT4). This is a desire to streamline and standardize care of a complex and highly individualized disease into a one-size-fits-all model for the masses. It is a desire for a simple, global solution, much like adding iodine to table salt! But it’s not working.

These are not honorable motivations worthy of today’s scientists and health care practitioners.

Mandating a monopoly of monotesting and monotherapy makes mere minions out of men.

If you think I am imagining such base motives, I challenge you to prove that they are not written into the vast majority of our restrictive guidelines. Are these motives not revealed by the way guidelines are used in professional tribunals like Mouton’s?

Narrow thyroid therapy guidelines and their misuse are holding back the improvement of thyroid therapy, restricting the independent critical judgment of intelligent professional physicians, and potentially costing millions of patients’ lifelong health and quality of life.

Get some moral courage. Exercise clinical judgment. Read those guidelines carefully and critically. Allow your peers to dissent. Prepare for a fight. We need you to stand up.

-Tania S. Smith

REFERENCES

Dyer, C. (2019). Doctor who practised “functional medicine” is suspended for nine months. BMJ, 367, l5916. https://doi.org/10.1136/bmj.l5916

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

Leung, A. M., & Braverman, L. E. (2012). Iodine-induced thyroid dysfunction. Current Opinion in Endocrinology, Diabetes, and Obesity, 19(5), 414–419. https://doi.org/10.1097/MED.0b013e3283565bb2

Midgley, J. E. M., Toft, A. D., Larisch, R., Dietrich, J. W., & Hoermann, R. (2019). Time for a reassessment of the treatment of hypothyroidism. BMC Endocrine Disorders, 19(1), 37. https://doi.org/10.1186/s12902-019-0365-4

Okosieme, O., Gilbert, J., Abraham, P., Boelaert, K., Dayan, C., Gurnell, M., … Vanderpump, M. (2016). Management of primary hypothyroidism: Statement by the British Thyroid Association Executive Committee. Clinical Endocrinology, 84(6), 799–808. https://doi.org/10.1111/cen.12824

Rayman, M. P. (2019). Multiple nutritional factors and thyroid disease, with particular reference to autoimmune thyroid disease. The Proceedings of the Nutrition Society, 78(1), 34–44. https://doi.org/10.1017/S0029665118001192