When Should Thyroid Patients Get A 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?

The 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.

The 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 judgement. 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?

The 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.