Mary
Shomon: From your book and prior articles, we know that
you both have been involved with thyroid work for over 25
years -- personally and professionally. What is your stance on
patients getting a second opinion?
Drs. Shames: As health
professionals, we are extremely supportive of personal
empowerment and self-care. In addition to books, friends, and
the Internet, we feel it is essential to maintain a beneficial
relationship with your doctor.
A good practitioner can assist you in proper diagnosis and
optimalmanagement of your thyroid issue, saving you years of
distress, expense, and hardship.
But, keep in mind that all doctors have their limits. Their
time, knowledge, and clinical experience are not infinite. It
is standard medical practice to call in another opinion when
needed. Usually it is the doctor who decides when another view
is needed on the case. In the thyroid arena, it is becoming
more and more common that the patient is making this decision.
As a doctor - nurse team, we are entirely supportive of this
more recent and much-needed development.
Mary Shomon: What do you
feel would make a patient start thinking along these lines?
Drs. Shames: For thyroid
patients, it generally starts early in the diagnosis phase, or
later in the treatment discussions. For example, at the onset
of a possible thyroid problem, a knowledgeable practitioner
takes a complete history, listening carefully to nuances, and
identifying patterns. Then, he or she performs the proper
physical examination and orders appropriate laboratory tests,
to ascertain exactly what is causing the symptoms. In this
way, you can accurately determine which treatments will be
most helpful to you. Don't sell yourself short. Make sure from
the beginning that your situation is properly diagnosed. If
your regular doctor does not check for thyroid as closely or
as carefully as you would like, by all means speak up. This is
especially true if you have any thyroid disease in your own or
any of your family's medical history.
If you have obtained information from friends or web sites
related to your condition, it would be a good idea to share
this with your practitioner to obtain further input. In these
instances, be alert to the response of your practitioner. If
your doctor acts as if your questions are a bother, or doesn't
answer directly, consider whether you are receiving optimal
treatment. You may need to augment this doctor's care with an
additional opinion. If your doctor doesn't know the answers to
your questions, ask if he or she can find out for you, or
direct you to the proper resource. You may need to shop for
this additional attention, just as you would shop for the
right mechanic, contractor, or other service you value.
Mary Shomon: Why do you
in feel a prospective thyroid patients need to shop around?
Drs. Shames: Many
primary physicians do not seem to be aware of the excessive
prevalence of low thyroid in the population, or of its
collective toll on the nation's health. As we have noted in
our book, investigations by university medical centers, as
well as by the Mayo Clinic, have determined that the
prevalence of thyroid conditions is quite high -- compromising
the health of as much as 10% of the population, and appears to
be very much on the increase. It has taken a long time for the
medical commu nity, which is largely focused on critical care,
to become aware of this dramatic situation.
Since the condition is usually not severe or life threatening,
it may simply not grab the attention of busy doctors. Also,
since the thyroid system controls so many aspects of physical
and mental functioning, the patients' long list of complaints
can seem unrelated and excessive to the clinician. The patient
may have a skin problem, a stomach problem, fatigue, weight
gain, hair or nail problems, emotional ups and downs, feel
chilly some of the time, and hot at others.
When confronted with this seemingly global array of symptoms,
the physician is often skeptical, and, rather than suspecting
low thyroid, may believe that this patient may have a
psychiatric problem like depression. Now the stage is set for
a diagnosis of depression, or something similar, with a
prescription for Prozac or Zoloft. This misses the true
underlying diagnosis of low thyroid, which is causing the
symptoms that include depression. If you feel strongly that
you are one of the millions of thyroid sufferers being
misdiagnosed in this way, then you may well need to shop
around and get a more detailed second opinion.
Mary Shomon: What about
a patient who perhaps has had a second opinion with a more
open-minded doctor, has had a more complete panel of thyroid
tests, is diagnosed (maybe for years already), and treatment
still isn't going as well as she or he would like. What then?
Drs. Shames: It is well
known that this unfortunate situation of less than
satisfactory treatment is all too common. Let's say your
particular problem is not with the diagnosis of a thyroid
issue, but with the ongoing interpretation of symptoms and
tests that could result in more optimal management of the
condition. When blood tests are read, the range defined as
normal for thyroid is frequently so large that what is
considered a satisfactory level can actually disregard the
unique metabolic needs of an individual person.
Such people can feel miserable for years with a variety of
significant complaints, despite their lab work having returned
to "normal". Regardless of the patients' protests, some
doctors insist that if your TSH is fine, then your thyroid is
fine. The thyroid patient, however, may be gradually feeling
worse and worse, and perhaps eventually becoming despondent.
If you are in this boat, you may want a second opinion from a
doctor who considers lab work as only one part of the whole
thyroid story.
Mary Shomon:
Unfortunately, my readers and I have found that doctors like
that are relatively few and far between.
Drs. Shames: That may be
true, but there are more and more of us. In our practice, we
do primary care as well as second opinions. Lab tests are just
one of the factors that go into our decisions and suggestions.
There are plenty of other doctors like us. Patients just need
to seek them out. Your Top Doctors Directory is an excellent
place to start.
For example, consider the doctor's "bible", the Physician's
Desk Reference (PDR) . In all the thyroid medicine sections,
there is a subheading called "laboratory tests." Here
physicians are advised not to rely solely on any one
particular blood test for managing low thyroid. Instead, they
are reminded to combine the knowledge obtained from laboratory
evaluation with good clinical judgment. Yet, with managed care
dictating protocol, physicians are by and large ignoring this
advice. A few physicians, however, are indeed following this
proper procedure; patients just need to find these doctors.
Then the patients can obtain a second opinion that hopefully
will inspire their primary doctor to be more open-minded about
treatment discussions. It may be that a simple increase in
medication dose or a simple change in brands of medicine will
be a big improvement. Maybe the second opinion will suggest
combining two thyroid medicines, which is sometimes better
than any one medicine alone. An open-minded primary doctor
then can utilize the second-opinion suggestions on a trial
basis and see how well it works.
Mary Shomon: Many
patients are not seeing the kind of doctors you are
describing. Why do you think there aren't more physicians who
take a similar approach to yours?
Drs. Shames: Since the
THYROID POWER book came out, we have been hearing from people
all over the country, voicing dissatisfaction with what has
been called "the tyranny of the test", or with the
unwillingness of their doctor to try something new and
different.
We can readily understand why many providers would not want to
practice in this manner. It is extremely time-consuming,
requiring an extra dose of patience to monitor each patient's
fluctuating progress. The process demands that the caregiver
walk side by side with the patient, educating and supporting
the person who is in the midst of this (sometimes)
roller-coaster existence. The managed care environment does
not allow practitioners to devote the careful attention that
is called for, to find just the right dose, of just the right
medicine(s), for each person.
In addition, the patients aren't usually acutely ill. Their
condition is more of a longstanding, chronic condition that
moves slowly. Some health providers do not have strong
interest in this mild situation.
It is also risky for the doctor to step out of the standard
mold, to try something slightly different. Keep in mind that
physicians are monitored, and are expected to practice in
accordance with a certain community standard. That means that
if seven general practitioners in a given city never prescribe
anything but synthetic thyroid, and the eighth GP sometimes
uses synthetics and sometimes uses natural thyroid, that
eighth doctor is not considered to be practicing in accordance
with the standards of the community. The actual legal risk is
minimal, yet it still discourages many doctors from
innovation.
Mary Shomon: I can
understand all that. What I, and many of my readers have
trouble with, is when the doctor's seem haughty or obstinate.
Drs. Shames: Oh, that's
a much bigger issue. Health care in general is long overdue
for a needed paradigm-shift in doctor-patient relationships.
It needs to become more of a co-equal and mutually-sharing
partnership for learning and healing. Many doctors are trained
to think that an omniscient demeanor is most reassuring to the
patient. In some cases this is true, perhaps mostly with older
patients, who have been indoctrinated to believe the doctor is
infallible. We believe, instead, that our job is to educate
and motivate, rather than dictate. The doctor should be
open-minded, willing to try a variety of different medicines,
and to help the patients decide which one is really working
best for them.
We consider that part of our role as caregiver is to empower
and honor the individuals who seek our knowledge, wisdom, and
support in safeguarding their health.
It is well documented that patients' beliefs play an integral
role in healing. It is also well documented that an empowered
patient does much better than one who simply follows orders.
We strongly consider that what the patients believe to be
good, or not good, for them is of utmost value in planning our
approach. If a patient has had negative experiences with
certain medications, we respect their concerns and
experiences. We encourage health care consumers to be sure to
articulate feelings and beliefs about treatment. If your
health provider is not interested in hearing your feelings or
beliefs, you may then definitely want to consider getting
another opinion.
Mary Shomon: Can you sum
this all up into a "nuts and bolts" recommendation list for
patients?
Drs. Shames: Absolutely.
Here is when a thyroid patient should start thinking about
getting a second opinion:
- If your doctor does not explain
your lab results or provide the actual numbers (this is
especially true if you ask for results and cannot get them
at all)
- If your doctor or office
representative will not return your phone calls
- If your doctor says that all of
this must be in your head, or be stress-related or PMS or
menopause related (of course it's all related, but thyroid
often needs to be considered as a primary cause)
- When your doctor says a particular
symptom you've seen on this website "couldn't possibly be
due to low thyroid" (red flag)
- When you've been on the same
treatment for years and are still not feeling your old self,
but your doctor is unwilling to change anything
- If you are lucky enough to have a
cooperative doctor, but he or she has been trying things
that don't seem to be working, or are making you worse (your
doctor may need some help to find just the find tweaking for
you)
Mary
Shomon: Finally, how can a second-opinion experience
achieve a positive result for patients?
Drs. Shames: Here's what
we've found is most helpful.
- It is best is to let your primary
doctor know that you would consider attending to the second
opinion suggestions as a "temporary" trial of something new.
If it doesn't work, you'll be content to continue working
with your doctor perhaps in another direction, or at the
very least, going back to what you had been doing before.
- Tell your primary doctor that you
are willing to take full responsibility for any adverse
outcome in trying out a second-opinion suggestion. In fact,
you are willing to sign such a statement in the chart (this
relieves a lot of pressure for the doctor, and puts you in
the drivers' seat).
- Let your primary doctor know that
you understand that optimal thyroid management is a very
individualized and sometimes "hit and miss" situation, that
you are perfectly willing to engage in, and that - in fact -
you consider it good medical care to engage this way because
you are suffering with an "intractable" and perhaps
unnecessary disability in your life (that medical lingo will
get more of your doctor's attention than simply saying "I
don't like feeling tired".)
An interview by
Mary Shomon as it
appears on her website
Thyroid-Info.
http://thyroid.about.com/cs/shames/a/secondopinion.htm |
