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The Pitfalls of Most Doctor Appointments

11:14am, July 12th.

I go to the doctor’s office and, of course, the general practitioner is 15 minutes late to the appointment. With fair skin and her hair in a casual ponytail, she looks to be in her early 30s, pretty young for a doctor. She smiles at me and asks me about my symptoms. We talk about the fatigue, weight gain, and many other things.

Finally, she says, "Do you have any family history of thyroid problems?"

I say, "Yes, my cousin had an enlarged thyroid removed.”

"Okay, we're going to have you do a few tests."

She checked three boxes on a slip of paper, and in a wavy motion signed her name at the bottom. She handed me the form. It was a lab order for 3 tests: TSH, T4, and 24-hour urinary cortisol.

This was an unfortunately scenario I had expected after a pre-appointment research session. Countless patient forum discussions warned of physicians ordering the wrong tests or insufficient test panels that would prevent them from ruling out potential causes and properly diagnosing a patient’s condition. In particular, there had been several warnings about doctors ordering TSH, “thyroid stimulating hormone”, when assessing thyroid function, when it wasn’t the most informative test. TSH is a hormone secreted from the pituitary gland, not the thyroid itself, so the test would would be unable to conclusively diagnose any type of thyroid disorder.

Even if TSH levels are in the “normal” lab values range, it wouldn’t rule out the possibility of low thyroid function due to other factors, some cases in which the thyroid gland functions properly, but is not receiving enough “signal” from the pituitary to produce sufficient levels of thyroid hormone, T3 (the active form), and T4 (the inactive form).

Alternatively, it could also mean the thyroid gland was over-producing hormone, and therefore prompts the pituitary to release less TSH because of the diminished need for more thyroid hormones.

In a third case, if TSH levels are high, the pituitary might be responding to the body's need for more thyroid hormone in the body, and not receiving enough thyroid despite the increased TSH, which may indicate primary hypothyroidism, in which the thyroid gland itself is failing to function.

In summary, if TSH levels are normal, it wouldn't rule out thyroid problems, primary or secondary. Therefore, tests other than TSH are always required for doctors to develop an informed diagnosis of the patient’s condition.

I walked into the doctor’s office with a list of 12 tests and specific notes to request the right tests: “free T4” instead of “total T4”, free T3 instead of total T3, vitamin D, vitamin B12, ferritin, folate, and some other tests. I had even printed copies of medical studies supporting the logic behind obtaining these tests. In short, the studies indicated that the measurement of free, unbound thyroid hormones would be more revealing about thyroid function than measuring simply measuring total T4.

As I inquired about these tests, "I'd like to also get vitamin B12, folate, and--", I was shocked by the doctor’s reaction.

She cut me off with an air of impatience, "B12 and folate aren't relevant to thyroid issues."

"I know I’m asking for many tests outside your normal procedure, but I’m hoping to rule out other causes besides primary hypothyroidism. There are some medical studies in these research journals that support this notion." I showed her the stack of medical studies, hoping she would reconsider.

She barely gave them a glance, before retorting back at me, "You can get these 3 tests today, and if there are any abnormalities, we’ll talk about additional tests."

"I would like to have all these tests done today so I can save additional trips to the lab, and in another appointment. This will save time."

"No, sorry, that's just not how it works."

"I have insurance. And I can also pay out of pocket if necessary."

She laughed. "No, it's not that. We just can't do that here."

Before I could ask about her reasoning, she added, "Anyway, I have to go to my next appointment." She stood from her chair, stepped towards the door, and turned the handle. As she casually swung open the door, she said, "You can go get tested at the building next door, on the second floor. Remember to take the lab slip. Have a good day." And then I was alone in the exam room, sitting on the crinkly white paper sheets.

All I remember afterwards was going home, infuriated.

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