Choosing the Right Doctor
In This Chapter
- Types of doctors to consider
- Identifying poor diagnostic attitudes
- Checking advice against lab results
- Identifying poor treatment approaches
Most major illnesses tend to be handled consistently and well throughout the medical community. In these cases you don’t have to worry about which doctor to choose, because you’re likely to receive a comparable level of care from any good doctor.
Unfortunately, that’s not the situation when it comes to thyroid disorders, which can make even skilled and caring physicians fumble. Thyroid diagnosis and treatment is a moving target, and what doctors are taught in medical school doesn’t always match up with the best practices of thyroid experts. Further, because the thyroid can cause any of dozens of seemingly unrelated symptoms, it’s easy for doctors who aren’t highly experienced with the thyroid to misinterpret the cause of a patient’s problems … or even dismiss those problems as being nothing more than the patient’s imagination.
As a result, if you don’t take an active role in ensuring you have the right thyroid practitioner for your needs, you may be playing Russian roulette with your health. This chapter guides you in understanding your options, what questions you should ask, and what behavior from your doctor indicates you’re receiving optimal care.
If you have reason to suspect a thyroid disorder—for example, if you have several of the symptoms described in Chapter 2—you should get your blood checked to determine your thyroid’s status. Specifically, your doctor should take a blood sample and send it to a lab, instructing the lab to test for at least three things: TSH, free T4, and free T3. The meaning of these tests are detailed in Chapter 7 (for hypothyroidism) and Chapter 11 (for hyperthyroidism). For now, what you need to know is that some less savvy doctors will order only a TSH test; but the TSH, free T4, and free T3 tests are all required to provide adequate information about your thyroid’s condition.
In addition, a sharp doctor will usually tell the lab to perform a one-time check for thyroid antibodies. These are indicators of such conditions as Hashimoto’s and Graves, which are the most frequent causes of thyroid disease.
Virtually any doctor can take your blood and send it to a lab, so you may find it easiest to begin with a general practitioner you already know and trust. Then again, if you want to be in the hands of a specialist from the start, you should seek out an endocrinologist.
Definition
An endocrinologist is a doctor who specializes in disorders of the glands of the endocrine system and their hormones. These glands include the thyroid, parathyroids, pancreas, ovaries, testes, adrenal, pineal, pituitary, and hypothalamus.
For example, the most common illness treated by endocrinologists is diabetes, which is typically caused by the pancreas not producing enough insulin. And the next most common illness is hypothyroidism, which is typically caused by the thyroid not producing enough thyroid hormones.
Regardless of the type of doctor you see, your physician should carefully question you about your symptoms, conduct a thorough physical examination of your thyroid, and perform at least a brief overall physical exam.
If your doctor then wants to run tests beyond the thyroid blood tests, that’s fine. In fact, it’s often the responsible thing to do, because your symptoms might be stemming from something that has nothing do with your thyroid. Alternatively, they could be caused by multiple problems that include but aren’t exclusive to your thyroid.
Here are some early warning signs that should make you seriously consider switching to a different doctor:
- You’re told to ignore a symptom—“It’s just in your head” or “Reduce your stress and it’ll go away.” It’s possible that’s true, but there’s no way to be sure until you’re tested.
- You’re told the only tests you need don’t involve your thyroid. It’s fine to test for other things, but in addition to checking your thyroid hormone levels. Thyroid tests are only around $50 each, and are covered by virtually all insurance plans, so there’s no good reason to not perform them.
- You’re told that the only thyroid test needed is the TSH test. That’s the sign of a doctor out of touch with modern thyroid diagnosis methods. You can either insist on having free T4, free T3, and thyroid antibody tests included until the doctor complies, or you can say “thanks but no thanks” and seek a physician with more up-to-date knowledge.
If your doctor doesn’t do any of these things, then you’re probably in good hands. Before you end your visit, however, ask if you can be faxed the thyroid test results after they come in from the lab. Be tactful when making this request, indicating that you know a little about what the numbers mean (which you will after reading Chapter 7 or Chapter 11), and you’re simply eager to get some idea of your thyroid’s condition ASAP.
If your practitioner seems a bit put off by the request, that’s not unusual, as doctors are accustomed to being fully in charge. But dealing with thyroid issues is a genuine collaboration between doctor and patient, and the best thyroid practitioners understand that. Be polite and diplomatic, and there shouldn’t be a problem.
If your doctor flat-out refuses, that’s another warning sign. In this case, ask if you can alternatively receive a photocopy of the results when you come in for your next visit. If you receive another no, then cancel the test and seek another doctor. You own your medical information and are legally entitled to it upon request. A doctor who denies your right to your lab data is also likely to deny your right to participate in your treatment.
Thyroidian Tip
If you don’t have a fax machine, you can get faxes e-mailed to you as PDF attachments. Some services will do this for free for the first 30 days and/or as long as you don’t exceed a 20-page limit (which is no problem, as your test results will typically fit on 1-3 pages). Alternatively, if you need ongoing fax capabilities, an especially good and inexpensive service is MyFax.com. To learn more, Google the phrase Best fax services.
Note: If your doctor detects one or more noticeable growths on your thyroid—that is, large enough to be seen and/or felt in your neck—then regardless of the results of the blood test, you must have these checked out, too. Your doctor can begin by prescribing an ultrasound exam, which is quick, inexpensive, and poses no health risks. If the results don’t clearly show the growths to be benign, there’s a small possibility of thyroid cancer. For safety’s sake, you should therefore follow up by seeing an experienced ear, nose, and throat surgeon (see Chapter 13).
Your Second Visit
If you asked for your thyroid test results to be faxed to you, then typically within a few days you’ll receive a page with some numbers on it from your doctor’s office.
To understand these results, read Chapter 7 (if you think you’re hypothyroid) or Chapter 11 (if you suspect hyperthyroidism). It will explain:
- What all the test numbers mean.
- The TSH range used by the lab, which we’ll call the broad range.
- The TSH range that savvy thyroid experts use, which we’ll call the narrow range.
If your TSH falls within the narrow range, then you probably don’t have a thyroid problem. If your TSH falls outside of the broad range, then you probably do; and your doctor won’t need any convincing to treat you with thyroid medication.
If your TSH falls between the narrow and broad range, however, you’re in a gray area that will make your diagnosis complicated. In this case your doctor should pay extra careful attention to your free T3 and free T4 results; and more importantly, she should look beyond the numbers to your symptoms. If your symptoms persist, and no other clear cause is identified for them, then you should be treated for thyroid disease regardless of the lab numbers. There’s no significant downside to treatment; and if you really do have a thyroid problem, then within 2-6 weeks you should start feeling better.
Having this knowledge makes you an informed patient, and empowers you to both understand and evaluate your doctor’s choices. When you see your doctor again, listen carefully as she discusses your thyroid test results, and notice whether what she’s telling you matches up with your own understanding. If you’re confused, don’t be shy about asking questions. (Sometimes doctors make shocking mistakes—for example, interpreting a high TSH to mean you have high thyroid levels, when it actually means the opposite.)
If your TSH happens to fall into the gray area between the narrow and broad ranges, also pay attention to whether your doctor dismisses the possibility that you have thyroid disease. If this occurs, mention that the TSH range recommended by the American Association of Clinical Endocrinologists (AACE) indicates you’re at risk, and that you don’t believe your symptoms are just your imagination. If your doctor dismisses this as well, then you need to find another doctor.
Alternatively, if your physician demonstrates she has a balanced view by taking both the lab numbers and your symptoms into consideration, and by not treating the lab’s recommended ranges as gospel, then the chances are she’s the right doctor for you.
Considering Treatment Options
If your doctor decides that you need thyroid treatment, then your next discussion should be about medication. If you’re seeing a mainstream doctor, he’ll probably prescribe Synthroid (or the generic version levothyroxine), which is lab-created T4. Most patients will do fine on Synthroid. However, many others—in my experience, as many as one out of three—will not.
The problem is that a healthy thyroid produces both T4 and T3 (in a 10:1 ratio), but Synthroid is exclusively T4. Many patients will therefore do better on a mix of Synthroid and Cytomel (which is lab-created T3), or on desiccated thyroid such as Nature-Throid (which is natural thyroid taken from pigs, providing a mix of T4, T3, T2, and T1). More information about these medications can be found in Chapters 3 and 8.
Therefore, it’s not inappropriate to ask your doctor to add Cytomel to the Synthroid; or to skip the synthetic route altogether and start off with desiccated thyroid. If he scoffs at the request and replies that Synthroid will always be the best choice, then he’s not giving you accurate advice, but don’t be too hard on him; he’s merely echoing what he was taught in medical school. If you find he’s a good doctor in all other ways, then you may want to give him a chance and see if you do well on the Synthroid.
One exception is if your thyroid has entirely stopped functioning or has been removed, in which case you’re relying exclusively on your medication to provide the thyroid hormones your body requires. In this case you’re really better off with desiccated thyroid medication such as Nature-Throid, because it’s the only option that will provide you with the full range of thyroid hormones—that is, T4, T3, T2, and T1. If your doctor won’t agree to your preference for medication, then you can start on Synthroid (which will do no harm), but also begin looking around for a different practitioner who’ll accommodate you.
If you need help locating an appropriate doctor in your area, use the website resources listed in Appendix B. These range from online patient recommendations of thyroid doctors to free searchable databases containing information on hundreds of thousands of physicians.
Thyroidian Tip
If your mainstream doctor won’t prescribe desiccated thyroid, you can find alternative doctors who will through the American Association of Naturopathic Physicians. Its website at Naturopathic.org allows you to search for doctors by specialty (select Adrenal Fatigue/Endocrinology) or by state. You can also get recommendations for alternative doctors through compounding pharmacies in your area, as these pharmacies typically stock desiccated thyroid. This is a bit tricky, however, because you don’t want a doctor who prescribes compounded thyroid medication (see Chapter 3).
Follow-Up Visits
Once you’ve begun treatment, your doctor should see you every 1-2 months until your condition appears to be stable.
First, your doctor should keep taking your blood to check your TSH, free T4, and free T3 levels. The initial dosage you were given was simply your doctor’s best guess. These subsequent visits will allow your doctor to fine-tune your dosage based on your test results. This is a trial-and-error process, so it may take months of mild adjustments until your doctor finds the prescription that’s perfect for you. Detailed information about dosages appears in Chapter 9.
In addition, at each visit your doctor should perform a quick physical exam and question you about how you’re feeling. If your symptoms are getting increasingly less severe, or have entirely disappeared, then the medication is working. But if that’s not happening, you shouldn’t hesitate to say so. What really matters aren’t lab numbers but whether your symptoms are being successfully treated. The latter is the most important indicator of your health and what your doctor should focus on.
If your doctor refuses to make treatment adjustments even though your symptoms show no signs of improvement, then have a frank discussion about your concerns. If you aren’t satisfied by your doctor’s answers, seek a more diligent practitioner.
Beware Extremists
A thyroid doctor who takes a hard-line approach in any direction is likely to be problematic. This chapter has already warned against mainstream doctors who believe Synthroid is the only appropriate medication for all thyroid patients. But you should also be wary of alternative doctors who proclaim that Nature-Throid is the only acceptable treatment. For example, if you require a finely tuned combination of T4 and T3, then a mix of Synthroid and Nature-Throid, or Synthroid and Cytomel, may prove to be ideal.
Here are some other approaches from alternative thyroid doctors that should set off alarm bells:
- No blood tests. If a doctor claims blood tests are unreliable, he’s living in the 1950s. Thyroid tests really were lacking decades ago, but modern tests are accurate and invaluable tools.
- Prescribing iodine overdoses. There’s no solid evidence that excessive iodine does any good; and there’s reason to believe it’s dangerous, raising the risk of developing Graves’ disease, Hashimoto’s disease, or thyroid cancer.
- Prescribing way too little thyroid medication. Some doctors outrageously underprescribe; for example, by telling patients to take their thyroid medication once a week instead of daily. This not only fails to cure symptoms, but stresses the endocrine system more than if no medication was provided.
- Prescribing way too much thyroid medication. You typically shouldn’t take much more than 1 mcg of T4 per pound of your body weight. Some alternative doctors instruct their patients to take four, five, or even six times as much thyroid medication as necessary. Over time this puts patients into a hyperthyroid state, which can lead to heart failure, accelerated osteoporosis, and other deadly disorders.
- Treating reverse T3. Some alternative doctors subscribe to a theory called Wilson’s syndrome that focuses on a byproduct of T4 called reverse T3, and they treat it with T3 megadoses. There’s no solid evidence to support these ideas, and the treatment is so dangerous that it’s caused deaths. Stay away.
- Prescribing compounded medication. There’s usually nothing wrong with compounded drugs—that is, medication prepared by a local pharmacy to a doctor’s specifications. It’s dangerous when it comes to thyroid medication, however, because the active ingredients in thyroid pills are so minute that even a small mistake by a pharmacist can result in an enormous overdose. Patients have died from such errors.
Additional details about these practices appear in Chapter 3. The bottom line is you should steer clear of doctors with these wrong-headed approaches, which have little connection to medical science and can put your health at serious risk.
Throat Quote
In the history of mankind, fanaticism has caused more harm than vice.
—Louis Kronenberger
Instead, look for a doctor who has is open-minded and has a balanced approach. If you’re exploring mainstream doctors, look for one who isn’t focused solely on lab results, but also pays careful attention to your symptoms and to how you’re feeling. And if you’re considering alternative doctors, look for one who makes full use of modern medical tools such as thyroid blood tests and doesn’t advocate wacky theories.
When it comes to thyroid care, a nuanced, middle-ground approach produces the best results.
- Ask your doctor to test your TSH, free T3, free T4, and thyroid antibody levels.
- Ask for your test results to be faxed to you so you can study them before your next doctor’s visit.
- Seek a doctor who’ll pay attention to your symptoms as well as your lab results.
- Follow up for trial-and-error testing to achieve your optimal dosage.