Some time ago I posted a blog asking if anybody knew of a doctor who was struck off for prescribing thyroxine. I got several replies - thanks for all who replied - confirming what thought i.e. none have.
I then submitted a Freedom of Information request to the GMC asking the same question. The GMC replied - no doctor has been struck off the GMC register for prescribing Thyroxine. They did limit their search to the last 5 years though.
Interestingly, they did send me the minutes of 4 cases of doctors who has been struck off for very serious matters. it seems that the doctors were reported for matters such as improper sexual relations , oh and he prescribed thyroxine as well, or this doctor is completely not up to standard, oh and he administered thyroxine as well.
I was also surprised to see in the minutes (but I have not seen the full transcripts) that the full accusation was prescribing thyroxine outside of guidelines. There was no mention in the minutes of the defence saying that a) there are no national guidelines and b)even if there were, it is acceptable to go "off guideline" if there is a good reason to do so. NICE say this.
To their credit, the GMC mainly cited only the serious matters when giving reasons for striking the doctors off the register.
No doctor has been struck off for prescribing thyroxine (in the last 5 years).
So the Endo has not complied with current Good Medical Practice (2010)
preamble: Be honest and open and act with integrity
para 56 Probity means being honest and trustworthy, and acting with integrity: this is at the heart of medical professionalism.
para 57 You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.
and in the new Good Medical Practice (2013)
in the preamble: Be honest and open and act with integrity.
para 65 You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession.
para 68 You must be honest and trustworthy in all your communication with patients and colleagues. This means you must make clear the limits of your knowledge and make reasonable checks to make sure any information you give is accurate.
Although this one lie may seem trivial, this fosters the scaremongering about treating patients who have hypothyroid signs and symptoms but also have blood results in the BTA reference range. This Endo is also a Professor and is likely to be teaching this lie to his students.
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NBob
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I will, as as part of a comprehensive complaint including the other lies and misleading statements he said to me
he Said,
1) 2 doctors struck off for prescribing thyroxine - untrue
2) there is guidance he has to follow - untrue
3) I am not hypoythyroid because my TSH was in the normal range - untrue/misleading
4) if he prescribes thyroxine he will be reported to the GMC - misleading
he's not prescibing thyroxine because a study showed it has no effect on biochemically euthroid patients - misleading plus practicing negative defensive medicine which is neglligent
I'm half way through my response with corroborating evidence.
You raise an interesting point. Not to my knowledge.
However, I am not sure that striking off the register is the proportionate response unless the doctor has seriously harmed patients.
Mt GP has harmed my health by not treating my obvious hypothyroidism due to negative defensive medicine. However, she has acted on the Endo's advice so I am complaining about him.
I am certain that patients have to complain. How far to take the complaint should be proportionate to the response of the doctor.
I work in Public Health dealing with matters that are prejudicial to health. We have to have a graduated approach to our "clients". Advice and guidance first. If there is no improvement we start the formal procedure. Warning letter, evidence gathering, Legal Notice, works in default, and prosecution as the last resort. In some cases, we see prosecution as a failure (we should have communicated better) but some people just will not do the right thing and need prosecuting. Doctors are no different despite what they think of themselves.
Some doctors will listen to patients and read the evidence patients give them - as they should do according to Good Medical Practice. (Advice and guidance)
Some will need a complaint to the CCG before acting properly.
Some will dig their heels in and, in my view; those are the ones who need to go to the GMC.
In my view, it is more important for the doctor to treat a patient properly. The purpose of a complaint is to highlight poor performance and to change that poor performance, not to punish a doctor.
In my view, striking off is appropriate (and in the public interest) for those doctors who have caused serious harm to patients.
The NHS says in its Constitution “You should give feedback – both positive and negative – about the treatment and care you have received, including any adverse reactions you may have had.”
The GMC expects patient feedback in the form of compliments and complaints fro evidence at Revalidation.
Phew, now back to work - Improving public health.
I think that study that thyroxine given to euthroid patients having no effect must have been the one my GP quoted to me, as part of the reason she wouldn't help. She's "very happy" with my thyroid. There must be copes of stuff out there to support trialling thyroxine. Does anyone know of any?
Hypothyroidism is a clinical disease with clinical signs and symptoms. Descriptions of the clinical features of thyroid dysfunction are given in publications such as Dr Tofts book "Understanding Thyroid Disorders" (Family Doctor Series - The British Medical Association )and "Thyroid disease - The Facts" (Bayliss RIS and Tunbridge WMG - Oxford University Press) and most importantly, Hypothyroidism Type 2: The Epidemic by Dr Mark Starr. the which are written for patients. Hypothyroidism is not a purely biochemical abnormality.
Using TSH reference ranges as a the only diagnostic tool is not logical because
1) there is little correlation of TSH to clinical status,
a) The aim of thyroid replacement therapy is to achieve a euthyroid state. This should be determined by the signs and symptoms of the patient rather than solely on the position of the pituitary hormone TSH in the disputed reference range. How useful is thyroid function testing in patients with recent-onset atrial fibrillation? Krahn AD, Klein GJ, Kerr CR, Boone J, Sheldon R, Green M, Talajic M, Wang X, Connolly S. Source University of Western Ontario, London. Arch Intern Med 1996, 156:2221-2224.
b) The accuracy of the TSH test in confirming a suspected diagnosis of hypothyroidism has not been adequately measured. The TSH test's accuracy has not been adequately measured for case finding and screening situations, either. Even though no one can honestly say what the sensitivity and specificity of the TSH test is for indicating hypothyroidism, this test is routinely used in the diagnosis of hypothyroidism as though the test was highly reliable. If diagnostic certainty of hypothyroidism is desired, the TSH test should not be utilized in the diagnostic confirmation of suspected hypothyroidism. Instead, diagnostic confirmation of suspected hypothyroidism should be accomplished by evaluating the patient's response to a trial administration of thyroid hormone supplements. If the patient's chronic symptoms are relieved soon after beginning thyroid hormone supplements, it is very likely that the treatment is compensating for hypothyroidism. Should the TSH Test be Utilized in the Diagnostic Confirmation of Suspected Hypothyroidism? Rand Wheatland Medical Hypotheses 2010;75(5):458-63
c) (There are) disjoints between FT4-TSH feedback and T3 production that persist even when sufficient T4 apparently restores euthyroidism. T4 treatment displays a compensatory adaptation, but does not completely re-enact normal euthyroid physiology. This invites a study of the clinical consequences of this disparity. Is Pituitary Thyrotropin an Adequate Measure Of Thyroid Hormone-Controlled Homeostasis During Thyroxine Treatment? Eur J Endocrinol. 2012 Nov 26. [Epub ahead of print].
d) To establish their role in monitoring patients receiving thyroxine replacement biochemical tests of thyroid function were performed in 148 hypothyroid patients studied prospectively. Measurements of serum concentrations of total thyroxine, analogue free thyroxine, total triiodothyronine, analogue free triiodothyronine, and thyroid stimulating hormone, made with a sensitive immunoradiometric assay, did not, except in patients with gross abnormalities, distinguish euthyroid patients from those who were receiving inadequate or excessive replacement. These measurements are therefore of little, if any, value in monitoring patients receiving thyroxine replacement. Are biochemical tests of thyroid function of any value in monitoring patients receiving thyroxine replacement? W D Fraser, E M Biggart, D St J O'reilly, H W Gray, J H Mckillop, J A Thomson British Medical Journal Volume 293 27 September 1986
e) Objective: The present study re-evaluates the inverse log TSH–free thyroxine (fT4) relationship, which has generally been assumed to characterize the thyroid pituitary hypothalamic feedback regulation in thyroid function. Design and Methods: The correlation between fT4 and TSH was analyzed in two data sets from differing time periods involving 3223 and 6605 patients referred for thyroid testing, representing the whole range of thyroid functions from hypothyroidism to hyperthyroidism. Results: We found that the data do not support a linear log TSH–fT4 relationship; instead, the correlation’s gradient varies with thyroid function. As a consequence, an alternate model, based on the error function, was introduced. When directly comparing the models by means of curve fitting, using F-test and Akaike criteria, the alternate model results in a significantly better fit. The model was verified in the independent second set of data. Subgroup analysis of untreated patients added further proof to the non-linear model. Conclusions: We propose a refined non-linear model to describe the relationship between TSH and fT4. It implies that TSH response to a deviating fT4 value may not be log-linear, but may be disproportionally related to the extent of the deviation from an optimum set point. A better understanding of the complex nature of the TSH–fT4 relationship may further the development of more precise clinical models and aid in better defining subclinical states of thyroid dysfunction. Also, it may encourage other biological interrelations to be reconsidered in the wake of advanced measurement techniques and more powerful computerized statistical procedures. Complex relationship between free thyroxine and TSH in the regulation of thyroid function Rudolf Hoermann, Walter Eckl, Christian Hoermann and Rolf Larisch European Journal of Endocrinology 162 1123–1129
f) We do not know how important the thyroid function tests are for making a diagnosis of thyroid dysfunction. It is a matter of personal judgment. Experience has shown that thyroid function tests, like all the signs and symptoms associated with hypothyroidism and hyperthyroidism, are not totally reliable. As it becomes clear that biochemical assessments cannot deliver the diagnostic accuracy expected of them, the fact that the clinical aspects of assessing thyroid dysfunction are being sidelined is a cause for concern. Doing more biochemical tests will lead to further confusion, not the hoped for clarity. The information obtained from thyroid function tests, despite its quantitative numerical appearances, is “soft.” How soft has yet to be established. Thyroid function tests—time for a reassessment Denis StJ O'Reilly BMJ 2000;320:1332-4 For clinical purposes and assay evaluation, neither the standard model relating logTSH with FT(4), nor an alternative model based on non-competitive inhibition can be reliably represented by a single correlation comparing all samples for both hormones in one all-inclusive group. Physiological states and functional relation between thyrotropin and free thyroxine in thyroid health and disease: in vivo and in silico data suggest a hierarchical model. Midgley JE, Hoermann R, Larisch R, Dietrich JW. J Clin Pathol. 2013 Feb 19. [Epub ahead of print]
g) Symptoms of hypothyroidism correlate best with 24h urine free T3. Thyroid Insufficiency. Is TSH Measurement the Only Diagnostic Tool? W. V. Baisier MD J. Hertoghe MD And W. Eeckhaut MD Journal of Nutritional & Environmental Medicine (2000) 10, 105–113
h) Measurement of serum TSH alone may not always reflect thyroid status Anthony D Toft Geoffrey J Beckett BMJ VOLUME 326 8 FEBRUARY 2003
i) While many endocrinologists continue to debate the appropriate levels of TSH to use as boundaries for normal limits, we believe using TSH to assess thyroid function is counterproductive, particularly in those patients attempting to lose weight. TSH is Not the Answer:Rationale for a New Paradigm to Evaluate and Treat Hypothyroidism, Particularly Associated with Weight Loss Carol N. Rowsemitt, PhD, RN, FNP and Thomas Najarian, MD Thyroid Science 6(4):H1-16, 2011
j) If TSH testing is the only test used then central hypothyroidism has to be suspected clinically otherwise the diagnosis is likely to be missed. Unsuspected central hypothyroidism A Waise, P E Belchetz BMJ 2000;321:1275–7
Perhaps prescribing might put someone in the firing line and then they are subject to scrutiny that brings up some trumped up reason to target the person who crosses the line, without any official policy being made. After all, Dr Skinner was dragged up in front of the GMC time after time, by other doctors and on very flimsy evidence, and I feel the constant harassment must have contributed to his untimely death.
I wonder if things get muddled between endocrinologists, and whether the doctor was referring to the late Dr S as he had problems with the GMC (although not struck off) and Dr P who wasn't struck off back in the day but relinquished.
I don't know if things get muddled along these lines, still misinformation if the Jedi was thinking of these two doctors. Either way you are right about doctors not saying misleading things and admitting the limits to their knowledge.
I'm wondering if this is part of a greater problem, where doctors are fearful in general to treat us, especially when T3 is involved.
It's still great to know that nobody has been struck off for prescribing thyroxine.
An endocrinologist told my daughter he could get struck off if he prescribed her levothyroxine. This was because her blood results were in range. She knows she has Hashimotos . Her symptoms are many and worsening.
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'heads up' for patients in Lancashire and South Cumbria wanting a T3 trail ~ "Liothyronine for NEW patients" now allowed by LSCMMG Review.
A forthcoming Bianco book
Complaint about endocrinologist and NW London ICS re liothyronine prescribing
Another Dr Skinner/Peatfield style case
