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Commentary on Professor Weetman's Article by Dr. Barry Durant-Peatfield

From Dr. Barry Durant-Peatfield

Updated: April 06, 2006

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Apr 6 2006

In his article mysteriously entitled "Whose thyroid replacement is it anyway?" Professor Weetman starts the discussion by taking the view that "there seems nothing more straightforward than the treatment of hypothyroidism." One certainly wishes that this simplistic view were true. Sadly, this is very far indeed from the case. Thyroid deficiency affects every organ, every tissue, every cell of the body, and in any degree from a mild dysfunction to complete failure; moreover, being human necessarily implies that sufferers are going to react differently. This makes, on the contrary, for very great complexity in the management of hypothyroid dysfunction.

It would be a great help if present assays, however robust, could be relied upon; but they cannot. The gold standard of measurement, the TSH, is subject to extreme error. The tissue thyroid receptors, the alpha 1 and 2 receptors and the beta 1 and 2 receptors, provoke a differing TSH response to cellular thyroid hormone deficiency; and the pituitary, affected by a period of hypometabolism, will have a dysfunctional response so that its TSH production may be down-regulated.

The measurement of serum thyroxine and serum liothyronine levels are similarly full of hazard. They are, as it were, a snapshot of blood levels, which may have a very limited relationship to the amount of T3 binding to tissue receptors, or the viability of T4 to T3 conversion, or indeed the availability of T4 from the transport protein. One reliable way of overcoming these problems is the assay of T3 and T4 excreted over 24 hours in the urine, a technique described by Baisier and Hertoghe; but, almost unbelievably, endocrinologists, if they are aware of this assay, unite in condemnation of it.

Nowhere has Prof. Weetman given any credence to the clinical appraisal of the hypothyroid state. A proper history and physical examination can make the diagnosis obvious to the physician. We have the examples of Murray and Hertoghe in the first two decades of the last century, whose descriptions of their clinical approach are without peer; and are just as true today as they were then.

In this world of evidence based medicine this has come to mean that the evidence is narrowed down to clinical assays only. It should go without dispute that the physicians' observation should not only be included in this evidence, but, indeed, have precedence over the tests. In this connection the Barnes Basal temperature test does not deserve the implied opprobrium heaped on it by Prof. Weetman. It is a most valuable tool as a screening test, and Prof. Weetman misunderstands its role when he suggests that it is used to make the diagnosis. In fact a low basal temperature points the way to a fuller clinical appraisal, and it is here that its great value lies.

"In this world of evidence based medicine this has come to mean that the evidence is narrowed down to clinical assays only." -- Barry Durrant-Peatfield

The dissatisfaction of patients as described in the listed submissions, is clearly extreme. Indeed, it is difficult to find a parallel anywhere else in medicine. There are really only two possible explanations for the anger and depth of feeling thus expressed.

That there are disaffected pressure groups intent on torpedoing the proper practice of medicine for an agenda of their own.
That the standard of care, diagnosis and treatment offered by practitioners falls so far short of reasonably expected standards that desperate patients want something done.

Prof. Weetman clearly discounts the second alternative, refusing to countenance the possibility that the conduct of himself and his like minded colleagues could possibly be at fault. Patients who have the temerity to conduct their own research and so question the rigidly held conclusions of their medical advisors are, it would seem, straying into fields of knowledge they have no right to go. In fact, these disaffected, and, be it said, ungrateful folk, are quite as bright as many of the doctors, and can work things out for themselves, successfully and correctly too. It is the fact that they do so which offends Prof. Weetman's sensibilities. These are matters, he feels, for only the informed and elected cognoscenti; not for the vox populi. It would perhaps be disingenuous to point out that one of the most serious, and least considered, complications of thyroid illness, is consequent adrenal dysfunction, which explains why so many patients stubbornly refuse to admit they are cured when the blood tests say they are.