Brittany is not done with her care, but I wanted to point out that in only 2 months she has seen better results than she has seen in years. She is also no longer burdened with the thinking she is hypothyroid. You’ve likely heard me say that overdiagnosis/incorrect diagnosis of hypothyroid is a problem and that often times it’s a problem in the gut leading to the symptoms attributed to the thyroid. These cases are why. Don’t make this mistake. I expect her loose stools to improve with a reduction in her vitamin C and that her fatigue will follow the trend of all her other symptoms and improve with time.
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How much vitamin D was her “Famous Thyroid Doctor” giving her? her level was 173! yikes.
Not sure, but likely too much. Zeleatry tends to permeate multiple areas; diagnosis, treatment, etc…
Just saw a patient who was seen by an ND. She had her on 96 capsules of supplements a day, and was inadvertently giving her 37,000 IU of vitamin D daily … for the good part of a year.
Well I guess the good news is there is a growing market for competent FM!
Just saw a patient who was seen by an ND. She had her on 96 capsules of supplements a day, and was inadvertently giving her 37,000 IU of vitamin D daily … for the good part of a year.
Well I guess the good news is there is a growing market for competent FM!
Well I guess the good news is there is a growing market for competent FM!
Dr Ruscio – I find a number of problems with your analysis. Many times what the patient tells us happened, is not always the conversation that took place with their Physician. I have had countless patients tell me that their Doctor said what sounded like outlandish advice. I was initially outraged that the Physician said something that sounded stupid or irresponsible. When I called this Physician, the story was actually quite different than the patient’s rendition. Many times, the response was quite reasonable.
I just finished an Integrative/Functional Medicine Fellowship with the American Academy of Anti Aging Medicine(A4M). We are routinely taught that lab values fall into two categories – “lab normals” and “optimal levels.” While the Thyroid levels on this lab report are technically within normal limits, they are not optimal. In the fellowship, we are taught the values that were hand written on this lab report – T4 1.1-1.2 and T3 around mid-value (in this case around 3.4) and a TSH <2 are optimal levels. . I have been taught this by multiple instructors – not just one.
Rather than being appalled, did you reach out to this Doctor to discuss the case?
I completely agree with you that a patient who does worse on a medication should be taken off of it. I disagree with you that a patient who is symptomatic with hypothyroid symptoms with suboptimal labs should not be tried on some sort of Thyroid support. This might include adaptogens, minerals, mitochondrial support, all the way up to Thyroid Hormone.
There are plenty of bad professionals out there. I am with you on the need to always do the right thing for our patients. I am a huge proponent and advocate of evidence based medicine. I have come to see that much in Integrative/Functional Medicine is based on anecdotal evidence from fellow practitioners who have seen good(or bad) results with certain therapies. In this case, many of my colleagues have seen positive results titrating thyroid hormone to achieve optimal levels, not dissimilar to the patient noted above. I find it difficult to believe that if a patient said that they felt terrible, and told their doctor this, that they would be continued on the same course of action.
Hi Eric,
All fair points.
1. I do agree that often times it’s not as bad as we are told. However, in this case the labs (which did not show hypothyroid) had written on them ‘call for Rx’ which was very premature.
2. Yes, the teaching of these values is the problem. It is subjecting far to many patients to thyroid hormone Rx. Hence this patients months of poor reactions. Considering a trial on thyroid Rx is absolutely an option, BUT this provider totally overlooked the gut and jumped right to an Rx. This is the problem. It’s the sequence in the hierarchy.
3. I don’t see any need to call the doctor to talk this out since we are not co-managing. Happy to have a conversation, but if I called every doc who made a questionable decision I’d be on the phone a LOT. But, also understanding that sometimes what I am hearing from a patient is overblown, YES. I take all patient reports with a grain of salt.
I’ll close with this – people being told they are hypothyroid (when they are not) and being started on thyroid Rx (when they don’t need it) is becoming a pervasive issue. The solution is leaving the Rx (in these non-hypothyroid cases) to a end-phase consideration. I have codified this into the algorithm I introduced in a prior issues of the review. So again, it’s not that thyroid Rx is wrong, it’s just being used way to early and without due circumspection.
I don’t propose to have THE answer here, but I feel my suggestions are better than the standard recommendations of the field. And, this is also what the evidence supports.
Thanks for your comments, keep the feedback coming!
I wanted to suggest Dr Kharrazian’s 2011 thyroid book as a nice resource of common thyroid patterns and non drug interventions for these patterns. I often refer back to this before starting thyroid hormone to make sure I have tried therapies of least potential harm. I find that it is sometimes difficult to resist persuasion by the patient to start hormones when they are feeling terrible, desperate for relief and lab values are perhaps suboptimal. I’m not saying this is ideal, but this is often what plays out in the office.
I wanted to suggest Dr Kharrazian’s 2011 thyroid book as a nice resource of common thyroid patterns and non drug interventions for these patterns. I often refer back to this before starting thyroid hormone to make sure I have tried therapies of least potential harm. I find that it is sometimes difficult to resist persuasion by the patient to start hormones when they are feeling terrible, desperate for relief and lab values are perhaps suboptimal. I’m not saying this is ideal, but this is often what plays out in the office.
Well I guess the good news is there is a growing market for competent FM!
How much vitamin D was her “Famous Thyroid Doctor” giving her? her level was 173! yikes.
Not sure, but likely too much. Zeleatry tends to permeate multiple areas; diagnosis, treatment, etc…
Dr Ruscio – I find a number of problems with your analysis. Many times what the patient tells us happened, is not always the conversation that took place with their Physician. I have had countless patients tell me that their Doctor said what sounded like outlandish advice. I was initially outraged that the Physician said something that sounded stupid or irresponsible. When I called this Physician, the story was actually quite different than the patient’s rendition. Many times, the response was quite reasonable.
I just finished an Integrative/Functional Medicine Fellowship with the American Academy of Anti Aging Medicine(A4M). We are routinely taught that lab values fall into two categories – “lab normals” and “optimal levels.” While the Thyroid levels on this lab report are technically within normal limits, they are not optimal. In the fellowship, we are taught the values that were hand written on this lab report – T4 1.1-1.2 and T3 around mid-value (in this case around 3.4) and a TSH <2 are optimal levels. . I have been taught this by multiple instructors – not just one.
Rather than being appalled, did you reach out to this Doctor to discuss the case?
I completely agree with you that a patient who does worse on a medication should be taken off of it. I disagree with you that a patient who is symptomatic with hypothyroid symptoms with suboptimal labs should not be tried on some sort of Thyroid support. This might include adaptogens, minerals, mitochondrial support, all the way up to Thyroid Hormone.
There are plenty of bad professionals out there. I am with you on the need to always do the right thing for our patients. I am a huge proponent and advocate of evidence based medicine. I have come to see that much in Integrative/Functional Medicine is based on anecdotal evidence from fellow practitioners who have seen good(or bad) results with certain therapies. In this case, many of my colleagues have seen positive results titrating thyroid hormone to achieve optimal levels, not dissimilar to the patient noted above. I find it difficult to believe that if a patient said that they felt terrible, and told their doctor this, that they would be continued on the same course of action.
Hi Eric,
All fair points.
1. I do agree that often times it’s not as bad as we are told. However, in this case the labs (which did not show hypothyroid) had written on them ‘call for Rx’ which was very premature.
2. Yes, the teaching of these values is the problem. It is subjecting far to many patients to thyroid hormone Rx. Hence this patients months of poor reactions. Considering a trial on thyroid Rx is absolutely an option, BUT this provider totally overlooked the gut and jumped right to an Rx. This is the problem. It’s the sequence in the hierarchy.
3. I don’t see any need to call the doctor to talk this out since we are not co-managing. Happy to have a conversation, but if I called every doc who made a questionable decision I’d be on the phone a LOT. But, also understanding that sometimes what I am hearing from a patient is overblown, YES. I take all patient reports with a grain of salt.
I’ll close with this – people being told they are hypothyroid (when they are not) and being started on thyroid Rx (when they don’t need it) is becoming a pervasive issue. The solution is leaving the Rx (in these non-hypothyroid cases) to a end-phase consideration. I have codified this into the algorithm I introduced in a prior issues of the review. So again, it’s not that thyroid Rx is wrong, it’s just being used way to early and without due circumspection.
I don’t propose to have THE answer here, but I feel my suggestions are better than the standard recommendations of the field. And, this is also what the evidence supports.
Thanks for your comments, keep the feedback coming!