Criminalizing Doctors Who Diagnose Hypothyroidism
Medical boards are responsible for taking disciplinary actions against physicians who practice medicine unprofessionally and dishonorably. Grossly repeating acts of negligence would be the basis for a board's taking action against a practitioner. A patient presenting to the ER in extremis complaining of abdominal pain, fever, and nausea who is diagnosed with flu and sent home when acute appendicitis is afoot would be an example of negligence. A patient undergoing a nonemergent hysterectomy who has her ureter severed during surgery would be an example of negligence. A patient experiencing fatigue, cold intolerance, dryness of the skin, brittleness of the hair, low grade depression, constipation, and chronic neck and back pain diagnosed with hypothyroidism would be an example of negligence. Right? Well, yes; if that patient with a chronically low basal temperature has a normal free T4 and normal TSH, the diagnosis assuredly is not hypothyroidism. It may be depression, it may be chronic fatigue, it may be xerosis, it may be back pain, it may be constipation; but it is not hypothyroidism. Why? Because hypothyroidism is diagnosed only when the TSH is elevated and free T4 is low. It does not matter if the patient has other thyroid function tests that are abnormal. It does not matter if the patient is given an empirical trial of thyroid supplement and has a positive clinical response. It does not matter if, after having a positive clinical response to being treated with thyroid, the symptoms relapse after the thyroid treatment is discontinued. Unless the TSH is elevated and the free T4 is low, a doctor may not diagnose hypothyroidism. To make such a diagnosis would be considered gross negligence, much like misdiagnosing appendicitis in the ER or clipping the ureter during abdominal surgery.
Broda Barnes, MD, championed the "alternative" hypothyroid diagnosis a half-century ago. His writing about the diagnosis and treatment of hypothyroidism has been well appreciated by the alternative medical community. The conventional endocrinology community has loudly rejected his theories and has made the diagnosis of hypothyroidism a laboratory diagnosis treated uniformly with synthetic thyroid preparations. In fact, most thyroid screening is limited to TSH testing only. If this result is normal, no further thyroid testing is necessary and the diagnosis of hypothyroidism is ruled out. When hypothyroidism is diagnosed, treatment is always based on prescribing levothyroxine and triiodo-thyronine, never the use of thyroid USP (Armour Thyroid). Treated hypothyroid patients are monitored with TSH testing – if the TSH level is below a defined level, the diagnosis of excess thyroid treatment is made and the prescribed thyroid is reduced in dosage. The diagnosis and treatment of hypothyroidism are not predicated on patient symptoms. It does not matter if there is symptomatic improvement. The only basis for making the thyroid diagnosis and prescribing medication is by testing the serum TSH level. Such is the "state of the art" of thyroid diagnosis in 2010.
The State of Oregon v. John E. Gambee, MD
John Gambee, MD is a physician practicing in Eugene, Oregon, who subscribes to much of the thinking espoused by Barnes. Gambee believes that the diagnosis of hypothyroidism is a clinical diagnosis made by understanding the patient history, examining the patient, assessing basal temperature, measuring thyroid functioning, and treating the patient with thyroid USP supplement. Unfortunately, the Oregon Medical Board does not share such philosophies. The Oregon board approves of thyroid diagnosis being made only based on abnormal TSH and free T4 testing.
In 1994 Gambee was disciplined by the Oregon Medical Board for "repeatedly demonstrating a willingness to move into uncharted waters in his practice without regard to the scientific merits of the proposed modality." Gambee's license was revoked but later reinstated. In 2004 Gambee's license to practice medicine was subjected to a modified stipulated order. The order required Gambee to "use thyroid function blood tests in conjunction with the history and physical in making the decision whether to use thyroid medication. (Gambee) is not to use thyroid medication unless the blood tests find a TSH level greater than the normal range and a free T4 below the normal range. While treating patients (Gambee) shall periodically retest the TSH level of his patients' blood no later than six weeks after initiating treatment and no less than annually thereafter. (Gambee) shall reduce the level of thyroid medication if the level of TSH falls below the normal range."
In January 2010, the Oregon Medical Board opened an investigation to determine whether Gambee violated the terms of the stipulated order. In May 2010, the board served Gambee with notification that he had violated the stipulated order by not following its terms for diagnosing hypothyroidism. In September 2010, the board issued an "emergency" order suspending Gambee's license based on his ongoing unprofessional conduct and gross negligence of diagnosing patients with hypothyroidism, exposing them to medical harm.
John Gambee is seeking to appeal the Oregon Medical Board decision. However, the board has not yet set a hearing date. Gambee is seeking relief by suing the medical board in federal court. In the interim, he is not able to practice medicine. Gambee's case deserves to be strongly supported. There is no evidence of gross negligence – just the artificial definition that hypothyroid diagnosis must be predicated strictly on laboratory measurements. No patients treated by Gambee for hypothyroidism suffered any harm. It is inappropriate for a medical board to characterize the "alternative" treatment of hypothyroidism to be a matter of gross negligence. The endocrinology community has drawn a line in the sand, making hypothyroidism a black-and-white diagnosis when the diagnosis is not so clear-cut. The alternative community who advocates treating hypothyroidism even when blood tests are normal should stand up now and support Gambee.
Inquiries and support for John Gambee should be directed to him: 93224 Highway 99 S., Junction City, Oregon 97448; 541-998-0111; firstname.lastname@example.org.
Dr. Gaby's 'Take' on Hypothyroidism
In Dr. Alan R. Gaby's milestone nutritional textbook, aptly titled Nutritional Medicine, the arguments are spelled out for diagnosing hypothyroidism when a patient has "normal" blood tests. In an eight-page chapter, Gaby raises reasonable scientific mechanisms to explain a patient's thyroid symptoms with a normal TSH, normal T3, and normal T4 test. Gaby talks about genetic abnormalities in the two deiodinase enzymes that could potentially interfere with the body's ability to convert T4 to the active T3 thyroid hormone. Additionally, he explains that there are two beta receptors for thyroid hormone and that these receptors can be dysfunctioning by genetic or biochemical mechanisms. Gaby cites extensive literature to support these hypotheses.
If you are treating hypothyroid patients who have normal blood tests, you want to read this paper and have it available to support a patient's thyroid treatment. It's only available in the textbook – but you also will have a source with 300 other chapters on nutritional medicine, all heavily referenced for support of nutritional treatment. This textbook is a must for office reference and provides more support for using botanical and vitamin and mineral therapy than any other book previously printed.
To order Nutritional Medicine, go to www.doctorgaby.com; call 603-225-0134; or write 12 Spaulding St., Concord, New Hampshire 03301.