James K. Rone, MD, FACP

A LARGELY STAND-ALONE DISCUSSION FROM THE APPENDIX OF MY UPCOMING BOOK ON OBESITY:

I have concerns about how the academic elite of medicine develop clinical practice guidelines intended to direct the care given by other physicians, as well as to inform insurers what ought and ought not be covered. There is a special need for scrutiny in this era where legitimate cost-containment, coupled with the increasing influence of third party payers, like federal and state governments, and the massive private insurance industry—which prioritize costs often over the wants and needs of patients and doctors—are driving “evidence-based medicine” and risk denying patients care and treatments not anointed by the “evidence.”

By this I mean a certain treatment or test, unless called for by a few top docs, at major medical schools, in their published guidelines, or supported by excellently conducted research reported in a scientific journal, might not be available to real-world patients. Perhaps worse, I think physicians today come out of training cowed by these top experts, devaluing their own thoughts and practice styles, subjugating them to evidence-based (“cookbook”) medicine. Keep in mind that every licensed medical doctor has an undergraduate degree, a four-year medical degree, and usually three-to-five-or-more years of post-graduate training. Such professionals are well trained enough to formulate their own preferred ways of managing patients, if encouraged and allowed (that is, paid) to do so, which they are often not.

Now, don’t misunderstand. Well-conducted research and peer-reviewed papers and clinical practice guidelines are necessary to good medicine. But once that information is out there, it should be the independent physician figuring out how to apply that data to each unique patient. No matter how good the research and conclusions, they can never anticipate all the variables confounding a real-world situation. And even if evidence-based medicine’s answers could be accepted as 100 percent valid, there will never be adequate evidence to answer every question faced by every physician in the course of one routine week.

Our original question from the text was:
Why did it take until less than ten years ago for low-glycemic-index dieting to get taken scientifically seriously? Smart people were talking about it. Why didn’t opposing theories get a fair shot at the height of the gung-ho all-fat-is-bad days? Isn’t the job of science to consider all possibilities, test for them, throw out ideas proved wrong, and refine ideas proved right, until gradually, inexorably we approach some great universal truth?

I used to think so.

Yet my experience has not always shown science to work that way.

There are several questions—low-fat versus low-carb being one, but there are others—in just my subspecialized area of medicine, where it seems to me experts wear bizarre blinders about even contemplating dogma-threatening new ideas. And I stumbled upon an explanation—or at least, objective confirmation of what I’ve observed—a mere few weeks prior to this writing.

Harvard-trained physicist, turned historian and philosopher of science, Thomas S. Kuhn (1922–1996) published a landmark book in 1962 titled, The Structure of Scientific Revolutions. In it, he threw out the notion that I had, and most of us have: That romantic view of science as, in the words of North Carolina State University philosopher, Jeffery L. Kasser, “straightforwardly cumulative, progressive, or truth-tracking.”

This traditional, romanticized image of science includes an “openness to criticism,” an almost obsession with disproving itself, that Kuhn felt did not exist in real-world science.

Normal science, according to Kuhn is governed instead by paradigms. A paradigm is an object of consensus, not open to criticism. The paradigm is assumed to be correct. It is dogma. It determines the puzzles to be solved, which involve fitting nature into the paradigm, and defines the expected results and the standards for evaluating those results. Science doesn’t seek truth, it seeks to prove the paradigm. “Dietary fat is unhealthy and the main promoter of obesity” was the paradigm in our discussion, and few mainstream researchers were allowed to, funded to, do research other than to prove that proposition. Read More 

THIS IS A EMAIL I SENT TO A COLLEAGUE, A SURGEON, IN FACT, AS A FOLLOW UP TO A DISCUSSION ABOUT A CHALLENGING SITUATION HE ENCOUNTERED IN THE OPERATING ROOM. HE BASED HIS INTRAOPERATIVE MANAGEMENT ON STANDARD, WELL-ESTABLISHED, WIDELY TAUGHT PRACTICES AND ASSUMPTIONS REGARDING THE DISEASE PROCESS INVOLVED. YET, THE FINAL SURGICAL PATHOLOGY YIELDED AN UNEXPECTED RESULT. WHEN I QUIZZED A WORLD-RENOWNED EXPERT ABOUT THIS CASE, HE ALLOWED, QUITE MATTER-OF-FACTLY, THAT THE RELEVANT ASSUMPTIONS ARE NOT PERHAPS VALID. YET THESE ARE ASSUMPTIONS WIDELY TAUGHT TO MED STUDENTS, RESIDENTS, ETC., BY HIM,AND ALL OTHER PROFESSORS IN THE FIELD (I’M BEING DELIBERATELY VAGUE HERE SO AS TO PROTECT THE PRIVACY OF ALL THE PARTIES. ANYWAY, I GOT TO THINKING…

It occurs to me that you have run headlong into what I see as a flaw in how contemporary allopathic, evidence-based Western medicine is practiced and taught—which I believe (at the risk of sounding melodramatic) puts our profession at risk. It is this issue which, in part, led me to write The Thyroid Paradox.

Namely, I believe that the inestimable diversity that is the nature of the biological sciences in general, and medicine in particular, demands that physicians recognize and be equipped to deal with that diversity—i.e., that almost every rule we come up with (in say the form of a clinical practice guideline[CPG]) will at some point be broken. It may only be broken one in a million times, but I believe a conscientious physician needs to be alert for that one case.

Thus, everything that we are taught and that is published in CPGs is by necessity an estimate of how things usually go, but they can’t reflect and be valid in all situations the physician will encounter in a lifetime of practice. My fear is that our current emphasis on evidence-based medicine codifies for younger, less-experienced, less-wise physicians “the typical” and deemphasizes and perhaps even devalues diversity.

In the book, I talk about the “academic elite,” who I believe, because they are super-intelligent and well-read and well-experienced, are aware of and embrace the diversity that I’m talking about, the fact that the “rules are made to be broken.” They are aware of and embrace these things in their own practices, and ruminations amongst themselves, and perhaps if we are lucky the occasional obscure case report. But when they teach medical students, residents, general internists, general surgeons, and when they write CPGs, they become very guarded, very dogmatic; the exceptions to the rules don’t get talked about much. And perhaps that is understandable, to a point—there is obviously a practical limit how much, say, endocrinology gets taught in a board-review course geared for family practitioners, for example.

It is also my belief, however, that there is a component of: They can’t handle the truth! That the “unwashed masses slogging the trenches of real-world medicine” need to be spoon-fed sound bites, rather than be trusted with the full width and breadth of the pathophysiology that’s out there. Subspecialists get let in on a few of the secrets, but often in an off-the-grid way.

I’ll give you two examples I cited in The Thyroid Paradox:

(1) Dr. Y is an eminent thyroidologist. I was fortunate enough that he flipped through a manuscript of The Thyroid Paradox when I happened to be sitting with him at an American Thyroid Assn. meeting. He zeroed in on a statement I made about considering thyroid hormone replacement for people with high-normal TSHs (say, >2.0). He said he disagreed, and his rationale was that the average clinical laboratory across the U.S. could not be trusted to run TSHs accurately enough, to support a standard of practice like that. Now, he has a point—we all must be cognizant of the statistical possibility of error in the diagnostic technologies we employ—but think about what he’s implying… He’s saying real doctors in the real world shouldn’t even consider trying to “heal” a whole population of possibly mildly hypothyroid patients, solely because they can’t be trusted to properly interpret and manage the data.

(2) It occurred to me after a number of years of treating hyperthyroidism and rendering people hypothyroid as a result—that some of them seemed to run lower TSHs than I expected as I adjusted their levothyroxine dose--in fact, some seemed to have undetectable TSHs on doses that otherwise seemed appropriate, or even too low. I reasoned that past hyperthyroidism, sometimes, resulted in hypothalamic-pituitary-thyroid-axis suppression that never recovered. Now, since this is a particular interest of mine, I have read everything I can get hold of, and listened to every lecture I can on this subject, over >15 years, and I can honestly say that I have never seen or heard it acknowledged that hyperthyroidism could cause permanent HPT axis dysfunction—transient, yes, not permanent. However, when I caught Dr. Z, a top endocrinologist, in the hallway at another ATA meeting, and proposed my thesis: He grinned and tossed back, and exclaimed, “Oh, yes, of course!”

OH YES OF COURSE!

Then why doesn’t anybody ever say it?

Because, methinks, we can’t handle the truth.

Food for thought…

Best,

jkr
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