A few months ago in a previous post I said that an important paper of ours setting out the logistics of thyroid hormone therapy and current failure to understand and use modern understanding was rejected fairly brutally by referees working for the British Medical Journal. This paper involved Dr Tony Toft with ourselves. We have now received an acceptance (with of course the need for some revision - this always happens) from Elsevier BMC Endocrinology. The reviewers actually praised the paper as "sophisticated and highly articulate" (trumps-blowing). One of these was a distinguished professor from Harvard who has written extensively on T4-T3 combo therapy.
Our paper crystallises all the thinking and conclusions we have come to in past publications. It combines politics with science in discussing the thought processes underlying classical beliefs (ie that TSH is all in diagnosis). I append here our closing conclusion:
Until the situation is clarified all currently available treatment options should remain on the table and the focus should remain on facilitating the free choice of prescriptible treatment options rather than imposing new restrictions. The biochemically based reason for the rise in patient complaints has to be addressed, not a shift on to them of blame and burden of proof.
This invites a resume of the current state of affairs.
It appears that what we are witnessing constitutes an unprecedented historic change in the diagnostics and treatment of thyroid disease, driven by over-reliance on a single laboratory parameter TSH and supported by persuasive guidelines. This has resulted in a mass experiment in disease definition and a massive swing of the pendulum from a fear of drug-induced thyrotoxicosis to the new actuality of unresolved designation of hypothyroidism. All of this has occurred in a relatively short period of time without any epidemiological monitoring of the situation. Evidence has become ephemeral and many recommendations lag behind the changing demographic patterns addressing issues that are no longer of high priority as the pendulum has already moved in the opposite direction. 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. Contrary to all proclaimed efforts towards a more personalised medicine, this has become a regulated consumer mass market as with many other situations. This is of little benefit to patients who will continue to complain, and with some justification, that the medical profession is not listening, thereby abandoning one of its primary functions in the doctor-patient relationship.
I will inform when the paper is published - it should be generally available then. However I think it demonstrates the mediocrity of much of British thyroidology.