Page 29 - Delaware Medical Journal - September 2017

ONE MEMBER’S OPINION
Physician: “No, I’ve been following you and the measurements have gone up.” Patient: “What are the symptoms of this disease?”
The physician then mentioned several symptoms.
Patient: “I have none of those symptoms.”
The encounter ended when the patient was given a prescription for levothyroxine; proffered as casually as one would advise taking Vitamin D. No thought was given to shared medical decision making. George Bernard Shaw’s remark that “the single biggest problem in communication is the illusion that it has taken place” comes to mind; in the above case, it hadn’t.
In a thought-provoking book, The Knowledge Illusion, the cognitive scientists Steven Sloman and Philip Fernbach make clear that we are increasingly bound together in the knowledge of others; we are a society that relies on experts. This is particularly so in medicine, as the bonds that inextricably link care giver and patient are trust and information.
In his 1963 landmark essay, “Uncertainty and the Welfare Economics of Medical Care,” the late Nobel laureate in economics Kenneth Arrow argued that medical care is an anomalous market; consumers are at a disadvantage as they must rely on the experts, physicians. He labeled this asymmetric information and stated, “Information, in the form of skilled care, is precisely what is bought from a physician.” While this commercializes the doctor-patient relationship and consigns
it to a cold marketplace — a buy and sell arrangement — it does also highlight that there may be considerable risk to the patient when the information is faulty or incomplete, as we shall see in my wife’s care. Access to medical information
via the internet has given some patients with the appropriate skill sets a chance
to challenge the information dispensed
by physicians, but physicians should
still dominate in the patient-physician exchange. Trust may also be lost when a patient challenges a proposed treatment particularly when an honest dialogue does not ensue.
The unstated diagnosis that was not discussed with my wife or with myself (the endocrinologist knew that I was a physician) is subclinical hypothyroidism. This common clinical problem in
older patients, particularly women, is

associated with a normal free T4 level. The prevalence is 20 percent in women older than 60 years and 28 percent of patients diagnosed with subclinical hypothyroidism progress to overt hypothyroidism within 10 years. This
is more likely in patients with a goiter
or with elevated thyroid autoantibodies. Although there is less controversy surrounding the diagnosis of subclinical hypothyroidism, whether to treat the disorder has led to highly opinionated pro and con camps.
Two of the more important reasons to treat subclinical hypothyroidism are to relieve symptoms and to prevent progression
to overt disease. While several studies have addressed whether levothyroxine was of value in patients with subclinical hypothyroidism, the results of the
large recent (TRUST) study —Thyroid Hormone Replacement for Subclinical Hypothroidism — of 700 patients over the age of 65 found that levothyroxine did such as tiredness, nor was there any of improvement in other outcomes, such as cardiovascular events. Most patients in the study had TSH levels below 10mU/
liter, an important observation. As well,

the trial with an elevated TSH reverted
to normal. They were excluded from the endocrinologist ignore compelling evidence or at the least not consider a joint medical decision of a disorder that many believe is overdiagnosed and overtreated?
It is not rare to see physicians bored and indifferent after years of practice and that may well be a part of what happened to our endocrinologist, seeing youthful enthusiasm fade into mid-life ennui.
Ronald W. Dworkin, physician and philosopher manqué, in his book Medical Catastrophe writes: “overspecialization has caused many doctors today to share in this feeling of monotony.....they grow depressed in spirit; they are overcome
at the assembly line with a daily state
of madness that lasts for ten hours.” Statistics support his beliefs: In a 2014 survey, 60 percent of physicians older than 45 had negative opinions about being a doctor.
This cynicism and entrenched pessimism does not bode well for the future of medicine in this country.
In the mean time we will be searching for another endocrinologist.
This is a column of personal opinion that

position.
CONTRIBUTING AUTHOR
■ JAMESF.LALLY,MDisaretiredRadiologist and a member of the Medical Society of Delaware Editorial Board.
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