Thyroid Research and Practice

: 2014  |  Volume : 11  |  Issue : 2  |  Page : 43--44

Quaternary prevention in thyroidology

Sanjay Kalra1, Manash P Baruah2, Rakesh Sahay3,  
1 Department of Endocrinology, Bharti Hospital and B.R.I.D.E., Karnal, Haryana, India
2 Department of Endocrinology, Excel Centre Hospitals, Guwahati, Assam, India
3 Department of Endocrinology, Osmania Medical College, Hyderabad, Andhra Pradesh, India

Correspondence Address:
Sanjay Kalra
Department of Endocrinology, Bharti Hospital and B.R.I.D.E., Karnal - 132 001, Haryana

How to cite this article:
Kalra S, Baruah MP, Sahay R. Quaternary prevention in thyroidology.Thyroid Res Pract 2014;11:43-44

How to cite this URL:
Kalra S, Baruah MP, Sahay R. Quaternary prevention in thyroidology. Thyroid Res Pract [serial online] 2014 [cited 2022 Dec 4 ];11:43-44
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Full Text

Though thyroidology, as other medical specialties, is a clinical science, it is also a preventive subject. Thyroidologists are often unable to "cure" thyroid diseases with one-point interventions, either surgical or medical. More often than not, the aim of therapy is to provide long-term support to ensure optimal quality of life and avoid preventable complications. It is this characteristic of thyroidology which makes it a preventive, as well as a clinical, science.

 Preventive Thyroidology

The concept of prevention has undergone significant change since it was first propounded for the control of acute, infectious disease. Prevention is now the byword for noncommunicable diseases as well. Thyroid dysfunction is linked with some of the four major diseases identified in noncommunicable disease control programs − cardiovascular disease, diabetes, cancer, and stroke. [1]

The concept of prevention has traditionally included primordial, primary, secondary, and tertiary levels. [2] The provision of iodized salt to prevent iodine deficiency and related thyroid dysfunction, at a mass level, has been a major success story of modern endocrinology. Screening for thyroid function in all patients with type 1 diabetes and for postpartum thyroiditis in all women with type 1 diabetes after delivery are examples of a primary prevention strategy. Secondary prevention in thyroidology takes the form of early diagnosis and treatment of thyroid dysfunction, to maintain optimal quality and quantity of life. This prevents avoidable worsening of thyroid disease. Tertiary prevention comes into play once thyroid dysfunction, or a complication, has occurred. Tertiary prevention aims to prevent or retard progression of complications. Timely administration of radioactive iodine, provision of nuclear medicine or surgical interventions, and management of comorbid conditions, may be termed as tertiary preventive strategies in the practice of thyroidology [Table 1].{Table 1}

 Quaternary Prevention

A "higher" level of prevention, however, has recently been suggested. This is termed as quaternary prevention. [3] Though quaternary prevention has been discussed in the context of related endocrine specialties such as diabetology and menopause, [4],[5] it has not received the much-needed attention it deserves in thyroidology.

Defined as "action taken to identify patient at risk of over medicalization, to protect him from new medical invasion, and to suggest him interventions ethically acceptable," quaternary prevention was first proposed by Jamoulle and Roland [3] as a conceptual framework for family practice. However, this idea is of utmost importance in thyroid disease management as well.

Thyroidology is a science in a state of equipoise. [6] In the current era of evidence-based medicine, thyroidologists are often unable to provide simple, single-line answers to a patient who asks a simple, single line question," Doctor, what is the treatment for my condition?" Hyperthyroidism can be treated surgically, medically, or by radioactive iodine ablation: all approaches have their advantages and limitations. Subclinical hypothyroidism and hyperthyroidism are clinical entities which require an individualized, person centric approach for management. Obstetric thyroidology is characterized by controversies which often overshadow consensus, [7] as is thyroid oncology.

With such background, it often becomes a challenge to practice "ethical thyroidology." Though recently released guidelines on clinical and professional ethics help the thyroidologist navigate the clinical management pathway they are not enough to help find solution to the many dilemmas encountered in practice.

The concept of quaternary prevention makes it easier to "identify patient at risk of overmedicalization." This phrase is one which has never been as necessary as today. Easy availability and accessibility of thyroid function tests has led to an increase in the number of diagnosed hypothyroid and hyperthyroid cases. [8] Unfortunately, it has also created an ''epidemic'' of wrongly diagnosed and mistreated "patients" who run the risk of overmedicalization and need "to be protected from new medical invasion." Putting this aspect of quaternary prevention into practice will help prevent iatrogenic hyperthyroidism and hypothyroidism that is becoming more and more common.

Availability of newer investigative and therapeutic modalities has also meant increased use, and misuse, of medical facilities in thyroidology. These include radiological, nuclear, and surgical procedures, which, in untrained hands, may do harm rather than good. To "suggest interventions, ethically acceptable," then becomes the duty of the clinical thyroidologist, who takes the responsibility of ensuring effective shared decision making for each person, based upon his or her unique situation.


1Park K. Park's Text Book of Preventive and Social Medicine. 21 st ed. Jabalpur: Banarasidas Bhanot Publishers; 2011.
2Levels of prevention. Available from: [Last accessed on 2013 Dec 8].
3Jamoulle M, Roland M. Quaternary prevention. Paper presented at the Hong-Kong Meeting of the Wonca Classification Commitee, June 1995.
4Kalra S, Aswathy S, Unnikrishnan AG. Quaternary prevention in diabetology. Submitted to J Pak Med Ass.
5Kalra B, Malik S. Quaternary prevention in menopause. Submitted to J Midlife Health.
6Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987;317:141-5.
7Kalra S, Baruah MP, Unnikrishnan AG. Hypothyroidism in pregnancy: From unanswered questions to questionable answers. Indian J Endocrinol Metab 2013;17:200-2.
8Kalra S, Kalra B, Sawhney K. Direct access testing in thyroidology: Perils aplenty. Thyroid Res Pract 2013;10:35-6.