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A Radical Approach to Medicine

What Doctors Must Do When Technology Isn’t Enough
November 25, 2018 | Comments

Editor’s Note: Richard M. Plotzker, MD works as an endocrinologist at Mercy Philadelphia Hospital.  He writes about endocrinology in contemporary practice. His Hormone Happenings series can be found HERE. Dr. Plotkzer comments regularly on Critica’s Facebook page, and is a fellow alum of the University of Pennsylvania.

One of my favorite undertakings these past few years has been to develop the Hormone Happenings series for www.medscape.com, which transmits essays I write to a predominantly medical audience. Readers of Hormone Happenings then respond online, ranging anywhere from zero comments to about sixty per essay, and an article in the series occasionally gets picked up by a related professional organization to transmit to another professional segment.  While the topics vary, they often involve identifying a report of new research that impacts on how physicians like myself make decisions.

Virtually all the published articles I discuss address commonly encountered but complex problems for which clear consensus is lacking.  It is always hoped that the new research I discuss will answer lingering questions and provide definitive answers though most advances come in small increments. Perhaps a new blood test will more accurately determine what is wrong or a new medication will work better than the old ones. All too often, new research offers guidance but also raises new questions. Practitioners, who do not have the luxury of waiting for research to provide them with the exact solutions for every individual patient’s needs, must navigate that uncertainty and exercise judgment amid incomplete knowledge.

Unsettling the Settled

Health care professionals inevitably struggle with uncertainty on a daily basis. Even things that seemed settled and routine often become complicated and less certain as medical research advances. What could be more basic than giving insulin to a person with diabetes whose blood sugar has surged to dangerously high levels? Yet what seems like medicine 101 has gone through major shifts in medical thinking since my days as a resident in the 1970’s.  Insulin is still started promptly for such patients, but for many years experts disagreed about exactly how much to give and whether insulin should be administered in hourly intramuscular injections or through a continuous intravenous infusion. As an endocrinologist who specializes in treating people with diabetes, I may be called on to decide how much to give and by which route for a patient in the emergency department with a life-threatening condition; I have learned to make decisions that work even though the scientific consensus may not always provide the ideal solution.

So how do we make decisions when the scientific evidence is not sufficient? Of course, we try to rely on all the dazzling tools of modern medical technology. We have so many laboratory tests and imaging possibilities today, that we and our patients often expect there to be a way to get a definitive answer to every problem. Sometimes, however, technology and modern science are not the only way to get the best result.  An old-fashioned technique, asking patients how they feel, is still an important tactic, as the following example will illustrate.

Treating the Patient, Not the Lab Test

One of the most successful medical interventions that has not changed appreciably for fifty years is the management of a very common condition called hypothyroidism, which occurs when the thyroid gland is unable to produce enough thyroid hormone. There are many causes of hypothyroidism, but the deficiency in hormone levels in all cases is usually easily detected by simple lab tests and for most conditions there is a widespread consensus among the experts as to what constitutes appropriate correction of this hormone deficit. That standard treatment is a single medication (called levothyroxine) that has multiple virtues: it is safe, effective, inexpensive, and only needs to be taken once a day. Doctors can monitor if they are giving enough medication by following results on the same lab test that detected hypothyroidism in the first place. Once the blood test results return to normal levels we know we are giving the patient enough medicine to restore normal physiologic balance.  Virtually all primary care physicians and nurse practitioners can take care of patients with hypothyroidism without help from specialists like me.

Yet despite all this seeming simplicity, patients are frequently dissatisfied with how they feel. They tell us that they are taking the medication just as the doctor or nurse practitioner prescribed, the blood tests are in the normal range, but the patient insists she doesn’t feel well. How can that be?

The research response to this seeming paradox asks two essential questions.  First, why don’t patients feel well when the lab suggests that they should? Second, can we use our current tools to get a better result?

A key study about this problem was recently released and I discussed it in my Hormone Happenings essay,  “Tinkering with Levothyroxine. Does it Make a Difference?”.   In this study, patients were randomly assigned to receive enough thyroid replacement medication to get them to a blood test level that is either considered a little low, right in the normal range, or a little high. Patients were not told, however, to which group they had been assigned. It turned out that measures of well-being, mood, and cognition did not differ among the three groups. Thus, although the lab test tells us if the patient is in the physiologically normal range, the information is not as helpful in telling us how the patient feels.

My take from the study is that in treating people with hypothyroidism we have to hit two targets, getting the lab test results close enough to normal that we are reassured no serious medical consequences will occur, and giving the patient enough medication so they actually feel better. That may mean giving more or less medicine than the lab test itself might indicate, or even switching to a different form of thyroid hormone replacement medication. But as my medical school professor told me [our class] many years ago, “remember, you are treating a patient, not his lab test result.”  This of course does not mean ignoring lab test results, which are crucial in managing many illnesses, but rather taking them into context with the many factors that physicians understand are part of a disease process.

While physicians are well aware of the educated guesses we sometimes are forced to make, patients may have gotten the impression that our modern tools and how we use them are better than they really are.  Along the way we need to transmit the reality of uncertainty to those patients and to the public in general and convey the fact that technology often presents us with several options, not a single definitive choice for the best treatment approach. Together with the patient, we must make educated guesses that take into account how people feel, think, and function. For one person with diabetes that may mean I have to prescribe three different medications; for another, adding diet and exercise to one medication may do the trick.  We always hope that new research will provide the optimal, one-size-fits-all approach for each situation as we encounter them.  But we also know that finding that approach is complicated and takes many years of research.

So, I will continue to do my best to make sure that my colleagues know all the recent, cutting-edge findings, published in the most rigorous journals. And I will expect them, as I expect myself, to be up-to-date on what that research shows. But I also know that when it is between me and my patient, we will have to face uncertainty together. And the extent to which I can help my patient feel comfortable with that uncertainty often determines how quickly we can get him or her better. Helping the public understand that coping with uncertainty is thus an important part of the scientific approach to medicine.

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