COMMENTARY

Defending the Cornerstones of Endocrinology

Richard M. Plotzker, MD

Disclosures

January 25, 2018

The late George Carlin, a truly funny fellow, became known for his comedy shtick spoofing the seven naughty words designated by the Federal Communications Commission as unsuitable for public broadcast. The Centers for Disease Control and Prevention (CDC), which has probably saved many more lives than most physicians will do over their entire careers, recently received its own list of medical profanity—again, seven words to be avoided, at the risk of budget cuts by the Trump administration or Congress.

Working for a private enterprise that seems a lot less punitive than the federal government, I still enjoy those elements of free expression that make medicine in general and endocrinology in particular the rewarding pursuit that it has been. So before I get professionally threatened in some repugnant way, I wish to expound on those now restricted terms which each have a unique importance to endocrinology.

Fetus: Thalidomide has no place in endocrinology. It has been associated with phocomelia, or failure of the fetus to develop limbs. The story of Miss Sherri of Romper Room captured the attention of America for months, ending with her decision to travel to Europe to terminate her pregnancy, in an era before Roe v Wade and before ultrasounds to diagnose the deformity antenatally.

Since then, the safety of medicines in regard to fetal development has been a high-level concern. My prescription pad commonly includes drugs with potential fetal harm, from spironolactone for hirsutism to ACE inhibitors, statins, and methimazole, all prescribed rather commonly. My prescriptions also include medicines to treat a mother more aggressively during pregnancy to protect her fetus. Levothyroxine is targeted to a lower TSH, and insulin is prescribed to women who probably would take nothing at all were they not pregnant.

To determine this took quite a lot of research, some still not entirely conclusive. And to disseminate these findings so that they become part of medical care, we depend on public agencies such as the CDC.

Diversity: This takes many forms. The same disease has many presentations. 21-hydroxylase deficiency can be potentially lethal in the neonatal nursery, diagnosed in grade school, or diagnosed in an adult seeking infertility or hirsutism evaluation, depending on where the abnormality occurs in the enzyme's amino acid sequence. We have all sorts of phenotypes labeled as type 2 diabetes, from obese insulin-resistant people to thin elderly patients with highly labile responses to small insulin doses. That is diversity of disease.

We have diversity of people, and a spectrum of patients seek care for noncritical conditions that have a variety of medically acceptable treatments. Some will opt for antithyroid drugs while others seek the permanence of radioiodine. Some diabetics live their lives from one fingerstick to the next and will accept very meticulous, often intrusive care, while others find this unacceptable.

The patients have great variation. Serving their needs and goals requires their providers to accept that diversity.

Vulnerable: If you are obese, you are subject to acquiring type 2 diabetes, sleep apnea, impaired mobility, and hypertension. If all of your recent ancestors had their first myocardial infarction before age 50, you are going to be charged more for life insurance. If your ancestors came from Africa, you are more vulnerable to the ravages of diabetes but somewhat protected from osteoporosis.

Medicine during my professional lifetime has evolved from intervention for the meltdowns of physiology, which we have gotten increasingly adept at reversing, to assessing risk and vulnerability of individuals and population so that those at most risk can be identified and tracked.

But there is another form of vulnerability, one that generates some despair among clinicians. Many patients have conditions amenable to a better remedy or prevention than their providers have been able to offer them. Barriers can be economic or they can be put on the back burner as a harried doctor addresses more urgent priorities in the 10 minutes of exam room time allotted. They remain vulnerable.

Entitlement: There is no shortage of political discussion or divergence of views among providers as to what care must be provided, no questions asked. The closest thing we have to guaranteed healthcare in the United States is the Emergency Medical Treatment and Labor Act (EMTALA), which only goes back about 30 years, while the Biblical imperative of Leviticus, "Thou shall not stand upon the blood of thy neighbor," has a much more ancient origin.

Certain "musts" far in excess of life-saving emergent rescue are widely accepted by physicians. My employment agreement and my contracts with payers require me to take care of beneficiaries to the extent that I have the capacity to do it. Patients can expect decisions to be made on their behalf within communal norms of care, and have any number of legal advocates soliciting them via public advertising when their entitlement to professional-level results fails.

And we medical providers have our entitlement, too. If we do our jobs, we get paid, whether by salary or by the insurers filling their agreed-upon obligation to us. "Entitlement" may be one of the bothersome words, but medical care would go belly-up without it.

Transgender: Now we travel from generic healthcare, or the more global concerns of civil engagement, to something directed more towards endocrinology, or away from the mission of the CDC, even though that is where this directive went. I suppose the CDC would be appropriately concerned when men wishing to live as women acquire their estrogens from veterinary sources intended for the dairy herds in upstate New York, which I have encountered professionally.

More typically, these patients have a much more restricted team of medical professionals, starting with pediatricians, mental hygiene professionals, eventually endocrinologists, and, for some, a surgeon.

Every Endocrine Society annual meeting has one or more sessions devoted to this issue. Attendance fills whatever room is assigned, as we all expect to encounter some of these individuals desiring hormonal intervention, while few of us see enough of this to acquire the same proficiency that we have in treating diabetes, thyroid, or adrenal conditions. Several meetings ago I learned that these people have a very high rate of teenage suicide attempts.

The numbers are a small subset of the population, but the dramatic consequences would be another reason to capture some attention of the CDC. Even if the CDC can be forcibly divorced from this element of medical care, the endocrinology and psychiatric communities cannot.

Science-Based: In the United States, the first 2 years of medical school are laden with biochemistry, anatomy, pathology, pharmacology. At any Endocrine Society annual meeting, scientists and clinicians attend in generally equal numbers.

Residents on elective tend to look askance when I ask them which hormones are amino acid derivatives and which are amino acid. As the options for controlling glucose have mushroomed over the past 20 years, science preceded each drug's development.

It is not at all like putting monkeys in a series of cubicles and hoping that one types the Great American Novel. We measure all sorts of chemicals and proteins nowadays but are indebted to the chemists who figured out how to quantify small amounts of substances. We look at MRI routinely, forgetting that nuclear magnetic resonance was fair game for my college organic chemistry exams long before anyone realized that cross-sectional imaging would make the exploratory laparotomy virtually extinct.

While clinicians can get a little rusty at the basic science that underlies what we do, and sometimes even regard the PhDs a little contemptuously in their separation from our patients, we all know that the medical care that has given patients a reasonable expectation of recovery starts in the laboratory before it gets to the exam room, operating room, or pharmacy.

Evidence-Based: When the reports of the political directives came to the attention of the senior CDC physicians and scientists, their initial internal responses transmitted to public media shortly thereafter defended most strongly their mission as an evidence-seeking institution. Evidence matters.

While physicians of my era bemoan some of the assault on our professional autonomy with endless audits on what fraction of our diabetics had eye exams or reached A1c targets, we accept that there is a benefit to patients of assuring that we implement what has been shown to pay off later.

There are always branch points and options for clinicians like myself to pursue, but there is also a body of evidence that guides what we should prescribe or what tests we should do. In recent years, I've gotten fond of looking over guidelines generated by the Endocrine Society, the American Thyroid Association, and other organizations of comparable stature.

For any disease, there may be 100 treatment recommendations. Each one has a designation of some type, indicating the strength of the evidence on which a recommendation is either made or sometimes deferred. Some are open and shut, others have a few pieces of the puzzle still to be sought. But modern medical care is less arbitrary and more evidence-based, with patients as the ultimate beneficiaries.

And while doctors might grumble sometimes about the audits and feedback, there is also a satisfaction inherent in knowing how to best implement the knowledge and skill that our efforts have brought us.

So these are really seven pretty decent medical terms that drive the public good, even if the representatives of the voters take a different view. The officials at the CDC wasted no time to defend their own professionalism, as should we.

There are some words that would not stir controversy. I'll pick the four that I wrote in the upper right-hand corner of my white board the day after the commencement speaker issued them at my son's college graduation:

Independence
Honesty
Accountability
Innovation

The speaker that day was also a business mogul–turned–elected official. He had a very good grasp of what civil engagement and pursuit of the public good require, imparting it well to my son, the other graduates who received all sorts of degrees from this university, and to at least one parent who kept the wisdom alive on his white board for 8 years.

The CDC's seven sensitive terms, when all is said and done, are really variants of the enduring four terms from the commencement address.

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