Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [22]
Patrick lost weight, and on a carefully controlled diet and a regular regimen of exercise, his blood sugar returned to normal. Now he took only one pill a day to keep his diabetes in check and didn’t need insulin. Patrick told us that when he first developed his symptoms of hyperthyroidism, he thought it might be due to his diabetes, that his sugar was out of control. But it wasn’t.
Because his insurance coverage had changed a few times over the years, Patrick had seen several diabetes specialists, and he’d discovered that they didn’t all agree on what was best for him, which oral medications to take, whether or not he should also be on insulin, and even how tightly he should regulate his blood sugar. “I know from my own work as a trainer that you need to individualize exercise regimens, because different bodies advance at different speeds.” Whenever Patrick worked with a client at the gym, he tried to define the person’s goals, desired weight, and level of fitness, and then they worked together, regularly assessing whether they were on the right track or needed to rethink their approach. He couldn’t imagine telling a client that there was one “best” path to fitness.
Although Patrick had no prior knowledge of Graves’ disease or the options for treatment, he felt he was being told—too quickly and too definitively—that there was one “best” approach. As it happens, clinical research supports Patrick’s thinking. A group of endocrinologists at the Karolinska University Hospital in Stockholm, Sweden, conducted a study to assess the benefits and risks of the three common treatments for Graves’ disease. They randomly assigned 179 patients to take antithyroid medication, undergo surgery on their thyroid gland, or receive radioactive iodine; the follow-up time was at least four years. The study showed that all three treatments were equally effective in controlling the disorder. Importantly, 90 percent of the patients were satisfied with their treatment—no matter which treatment they’d had—and would recommend it to a friend.
What Patrick experienced with his endocrinologist reflects a common and understandable phenomenon: The doctor projects his or her own preferences onto the patient. This has been documented in studies of a wide variety of conditions ranging from asthma to autoimmune arthritis of the spine, from prostate cancer to esophageal disease. Here, the endocrinologist truly believed that radioiodine therapy was best. His reasons for preferring this treatment were that it was simple—one radioiodine pill—and definitive—“problem solved.” But not every endocrinologist shares this view. An international survey of thyroid specialists showed that about two-thirds of American endocrinologists favored radioiodine for treatment of Graves’ disease, but only 22 percent of European and 11 percent of Japanese specialists did. Outside the United States, endocrinologists favored antithyroid drugs. Endocrinologists around the world have access to the same data from clinical studies and are schooled in the risks and benefits of each treatment. Yet the default option, presented as what is “best” for the patient, is strikingly different in these three regions. Part of the reason for this difference is likely cultural. The Japanese experience with nuclear weapons at Hiroshima and Nagasaki undoubtedly colors their views on radiation exposure. The 2011 earthquake and tsunami that