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When to Get a Second Opinion
Help Ensure You Get The Best Thyroid Treatment
An interview by Mary
Shomon as it appears on her website Thyroid-Info.
http://thyroid.about.com/cs/shames/a/secondopinion.htm
Mary Shomon
From
your book and prior art icles,
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 st art thinking
along these lines?
Drs. Shames
For thyroid patients, it generally
st art s 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 p art icular 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 p art 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
st art .
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 p art icular
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 p
art nership 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 p art 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 art
iculate 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 st art 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 p art icular
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 ch art (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
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