Latest / The Antisocial Doctors Podcast / Episode 4: Do I Need A Full Thyroid Panel?

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Episode 4: Do I Need A Full Thyroid Panel? · The Antisocial Doctors Podcast

1:27
Sonia Singh MD: You are listening to the Antisocial Doctors Podcast, hosted by me, Sonia Singh, a board certified internal medicine physician with a Master's in nutrition and a special interest in health anxiety
1:38
Rebecca Berens MD: and me, Rebecca Barons, a board certified family medicine physician with a special interest in disordered eating.
1:43
Sonia Singh MD: We're also a millennial women anxious moms and curious humans navigating social media.
1:48
Sonia Singh MD: We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
1:56
Rebecca Berens MD: This podcast is meant to be the antidote to your doom.
1:58
Rebecca Berens MD: Scrolling, a, solve for the anxiety, stress, guilt, shame, and confusion.
2:02
Rebecca Berens MD: That comes from social media's messaging around health.
2:05
Rebecca Berens MD: In each episode, we discuss a health related talk trending on social media with curiosity, nuance, evidence, humility, and compassion.
2:12
Sonia Singh MD: This is not your average debunking podcast.
2:14
Sonia Singh MD: We wanna explore not just what is trending on social media, but why?
2:18
Sonia Singh MD: Why are so many people drawn to this?
2:20
Sonia Singh MD: What is the nugget of truth here?
2:21
Sonia Singh MD: What are the facts?
2:23
Sonia Singh MD: What can we learn from this as patients and doctors?
2:25
Sonia Singh MD: No shame.
2:26
Sonia Singh MD: No blame, no snark.
2:27
Rebecca Berens MD: We're so glad you're here.
2:38
Sonia Singh MD: Okay, so let's get started.
2:41
Sonia Singh MD: Hi, Rebecca.
2:43
Sonia Singh MD: Hi Sonia.
2:43
Sonia Singh MD: How are you?
2:43
Sonia Singh MD: I'm good.
2:44
Sonia Singh MD: How's your week going?
2:46
Sonia Singh MD: It's going okay.
2:47
Sonia Singh MD: So I'm gonna be open and honest here.
2:50
Sonia Singh MD: I am like really nervous to record this episode because the topic today is thyroid testing.
2:57
Sonia Singh MD: And this is a topic that I just think there's a lot of people that are very passionate about it.
3:04
Sonia Singh MD: And one of the things I think we'll uncover over the course of this episode is just that a lot of information that's out there, it conflicts with what our medical guidelines tell us to do.
3:14
Sonia Singh MD: And so I think there's just a lot of controversy and disagreement on this topic.
3:19
Sonia Singh MD: And I am, I'm nervous that there's going to be people who do not listen to the entire episode and just hear a few snippets or even just look at the topic and.
3:28
Sonia Singh MD: Decide that we're gaslighting them or we're narrow-minded or that we just dunno the physiology well, or, 800 other things.
3:37
Sonia Singh MD: So anyway, I'm nervous about that,
3:40
Rebecca Berens MD: yeah.
3:40
Rebecca Berens MD: I think it's an important topic and I think this particular issue is emblematic of the way we communicate past each other about some of the issues in medicine where it's like the patient is feeling one thing.
3:52
Sonia Singh MD: Yeah.
3:52
Rebecca Berens MD: And it is important and it is relevant.
3:55
Rebecca Berens MD: And we are testing another thing to roll that out.
3:58
Rebecca Berens MD: And normal results of that testing doesn't mean that what you're experiencing is not real.
4:05
Rebecca Berens MD: Yeah.
4:05
Rebecca Berens MD: Or that it also does.
4:06
Rebecca Berens MD: And it also doesn't mean that there's not.
4:10
Rebecca Berens MD: Something going on that is, potentially relevant to your thyroid.
4:13
Rebecca Berens MD: It just is, the medical guidelines in this case are about thyroid treatment.
4:19
Rebecca Berens MD: And I think that's where things get misconstrued is like a lot of times when people are talking about, thyroid testing, what they're actually testing for are things that are not related to thyroid function.
4:32
Rebecca Berens MD: But affect symptoms related to thyroid.
4:34
Rebecca Berens MD: So anyway, we'll get into the topic I think.
4:36
Rebecca Berens MD: Yes.
4:36
Rebecca Berens MD: That's a great, this is like a perfect example of talking about the same thing, but we're actually talking about two very different things.
4:42
Rebecca Berens MD: That's happens a lot in medicine.
4:43
Sonia Singh MD: No, and you're right.
4:44
Sonia Singh MD: And it is a microcosm in that like a lot of the themes that emerge from this are recurring themes in a lot of our episodes.
4:50
Sonia Singh MD: And so that's always nice to.
4:52
Sonia Singh MD: See those threads, those common threads.
4:54
Sonia Singh MD: Okay.
4:54
Sonia Singh MD: So as always, we're gonna start the episode with a patient story.
4:58
Sonia Singh MD: I had a patient that joined my practice a few years ago.
5:01
Sonia Singh MD: She's still with me.
5:02
Sonia Singh MD: One of my favorite patients, I guess you're not supposed to have favorites, but one of my favorite, but her story was that she had been diagnosed with subclinical hypothyroidism by her previous PCP.
5:13
Sonia Singh MD: So she had gone in not feeling right, having some symptoms.
5:17
Sonia Singh MD: They said, Hey, look your TSH test is abnormal, but your free T four test is normal.
5:23
Sonia Singh MD: So at this point, the recommendation was we're gonna monitor this and recheck it.
5:27
Sonia Singh MD: We can talk about maybe medication.
5:29
Sonia Singh MD: So she heard this diagnosis and immediately thought I wanna be proactive.
5:34
Sonia Singh MD: I do not wanna end up on thyroid medication.
5:36
Sonia Singh MD: I want to do something preventive.
5:38
Sonia Singh MD: I'm willing to change my lifestyle.
5:40
Sonia Singh MD: I'm willing to change my diet.
5:41
Sonia Singh MD: I need more guidance on how I can do this.
5:43
Sonia Singh MD: And she didn't feel like her doctor gave her any of that.
5:47
Sonia Singh MD: So she ended up seeking care with an alternative practitioner who did a full thyroid panel, which is the topic of today's episode.
5:55
Sonia Singh MD: And that practitioner diagnosed her with Hashimoto's thyroiditis.
5:59
Sonia Singh MD: I think when she got this new diagnosis and this new name and this new label, she had this immediate feeling of oh my goodness.
6:05
Sonia Singh MD: Thank God this person has gone an extra step.
6:08
Sonia Singh MD: And done more testing and determined what the cause of my thyroid dysfunction is.
6:13
Sonia Singh MD: And this person was offering her all kinds of treatment recommendations.
6:17
Sonia Singh MD: So they basically told her, look, your antibody levels are so high, you are super inflamed.
6:21
Sonia Singh MD: You need to work on an anti-inflammatory diet.
6:24
Sonia Singh MD: They had her cut out gluten, they had her cut out dairy, she was avoiding cruciferous vegetables.
6:28
Sonia Singh MD: And they gave her this huge variety of supplements like iodine, selenium, a bunch of other thyroid support things.
6:34
Sonia Singh MD: Initially I think she felt really taken care of and heard and validated and empowered by all of this information, and she went out and tried to start doing it.
6:45
Sonia Singh MD: And I think, in comparison to her experience at her PCPs office where she felt like someone just said, yeah, these are the numbers.
6:53
Sonia Singh MD: You could take a medication or not take a medicine, you can take it, in a few months.
6:58
Sonia Singh MD: You may end up on medicine eventually.
7:00
Sonia Singh MD: There's nothing you can do to prevent it.
7:02
Sonia Singh MD: I think compared to that experience, this was a really positive experience.
7:05
Sonia Singh MD: So I think stories like hers, honestly I hear them not infrequently.
7:11
Sonia Singh MD: And I think stories like her lead to this big group of people and this movement that believes that, if you go to your doctor and they're only checking like one to three thyroid labs, that you're not getting the full picture and that's not enough to evaluate your thyroid health and you're missing out and you need to be getting this full panel.
7:29
Sonia Singh MD: I'm gonna update you on what played out with the patient at the end of the episode, but we'll leave it at that for now.
7:35
Sonia Singh MD: But I've had several people like her, but she is the one that I remember the clearest and I'm sure you've seen people who have had similar experiences.
7:42
Rebecca Berens MD: Oh, absolutely.
7:43
Rebecca Berens MD: So yeah, I'm excited to hear all that we're gonna talk about in this episode.
7:47
Rebecca Berens MD: But let's start with, know what is the claim that's made around.
7:52
Rebecca Berens MD: The full ARD panel compared to the traditional testing that we are doing in a regular PCPs office.
8:00
Rebecca Berens MD: What's the claim about, what is the actual difference between those things and then what's the claim about why it's better to do a full panel?
8:05
Sonia Singh MD: Yep.
8:06
Sonia Singh MD: So in this episode I'm gonna focus a little bit on evaluation of hypothyroidism, just because that is the most common thing that people, present concerned about.
8:16
Sonia Singh MD: And just to simplify and keep things a little bit limited'cause it's such a big topic that we could go on and on if we were also including other dysfunction of the thyroid.
8:25
Sonia Singh MD: So we're gonna focus a little bit more on hypothyroidism and Hashimoto's, but I think the claim is just that if you are concerned about low thyroid function, that you need this full thyroid panel and it's not adequate for your doctor to just be doing one, two, or three thyroid labs and telling you that your thyroid is normal.
8:43
Sonia Singh MD: Now, what is a full thyroid panel?
8:45
Sonia Singh MD: Again, a common thread here is a lot of these terms don't actually have any standard definition and they vary depending on what source you're looking at.
8:53
Sonia Singh MD: But from a few different sources I looked at what generally they're referring to is beyond just a TSH a a free T four, and a total T three.
9:01
Sonia Singh MD: It's TSH plus total and or free T three plus total and or free T four, reverse T three, anti TBO antibodies, anti-thyroid globulin antibodies, and possibly thyroid stimulating immunoglobulin, which is really more for hyperthyroidism, but basically, more like six to seven tests evaluating your thyroid function.
9:24
Sonia Singh MD: The question is why has this become viral?
9:28
Sonia Singh MD: I have a long list of ideas.
9:30
Sonia Singh MD: I'm curious to hear your thoughts of why you think this particular panel and request for labs and the thyroid has been such a.
9:38
Sonia Singh MD: Hot topic for so many years.
9:41
Rebecca Berens MD: Yeah.
9:41
Rebecca Berens MD: I think the thyroid conditions can affect so many symptoms.
9:46
Sonia Singh MD: Yeah.
9:47
Rebecca Berens MD: There's so many symptoms of thyroid conditions, particularly hypothyroidism that are common and are frustrating and are difficult to often find a clear cause like fatigue, for example.
9:58
Rebecca Berens MD: Yeah.
9:58
Rebecca Berens MD: So many things can cause fatigue.
9:59
Rebecca Berens MD: So many of us feel fatigued and and there's likely more than one thing affecting fatigue in a given person, but it feels great to be like, I wish I, I could find one answer and then there I would find the solution and then I could fix it and then I won't feel this way anymore.
10:15
Rebecca Berens MD: And I think that's true of a lot of the symptoms that come along with hypothyroidism and when you get back, maybe that basic TSH maybe plus or minus a free T four as the screening test in your PCPs office.
10:27
Rebecca Berens MD: And they're like, oh your thyroid's normal and you don't have any other explanation.
10:31
Rebecca Berens MD: And then someone else that you go to, like in your example is actually they just didn't do the right test.
10:35
Rebecca Berens MD: And look at all these things that are wrong with you, and if we fix it, we can fix all your problems.
10:39
Rebecca Berens MD: It feels very exciting to have an answer and there's something you can do.
10:44
Rebecca Berens MD: And so I think people are really drawn to that.
10:46
Rebecca Berens MD: And the thyroid just is such a, has such pervasive effect on the body that it is commonly the one that people go to when nothing else is found.
10:58
Sonia Singh MD: Yeah, I totally agree.
11:00
Sonia Singh MD: So what I had written down was just so many of the symptoms of thyroid disease can be subtle variable, not that specific.
11:07
Sonia Singh MD: It's almost like reading a horoscope, where you read something and you're like, that sounds like that could be me.
11:11
Sonia Singh MD: And I think what the experience a lot of people have is that they read that list of symptoms or they read about it somewhere, and then they become anchored on that diagnosis where they're like, oh my God, that must be it.
11:23
Sonia Singh MD: That seems like it checks all the boxes of what I'm experiencing.
11:25
Sonia Singh MD: That's gotta be it.
11:27
Sonia Singh MD: And I will tell you, even as a clinician, sometimes I have felt like that.
11:31
Sonia Singh MD: I've definitely seen patients where I'm just like, this person definitely has hypothyroid.
11:35
Sonia Singh MD: They've got, I, their TSH is gonna be 20.
11:37
Sonia Singh MD: I just know it.
11:38
Sonia Singh MD: And it is a little crushing when you get the results and you're like, God darn, that's not what it is.
11:44
Sonia Singh MD: Of course you don't want your patient to have a disease, but it's so nice to have a nice, neat explanation where you're like, ah, yes, they have these symptoms, and look at the tests they match and we know what the treatment is.
11:54
Sonia Singh MD: And so I think for honestly, both patients and doctors, mostly patients, it's a very frustrating, invalidating, disappointing experience when you had hope that there was this explanation for what you were feeling and everything was gonna be tied together and explained by this, one issue and then you're getting told by your doctor based on one or two tests.
12:15
Sonia Singh MD: No, it's not actually that.
12:16
Sonia Singh MD: I think part of it is, like you said, the thyroid is just such an important and complex organ that does so many different things that.
12:23
Sonia Singh MD: Those symptoms, which can be caused by a variety of other issues, can just look.
12:29
Sonia Singh MD: So much like the description of hypothyroidism that we, have in our textbooks and that you can find on PubMed and Healthline and all of those sites.
12:36
Sonia Singh MD: I think a big part of it is that but I also think, a big part of it is that we leave a lot of gaps in terms of explaining to people that okay, you are having these symptoms.
12:47
Sonia Singh MD: They are real, they're not imagined, they're real.
12:51
Sonia Singh MD: This test is telling us that it's not your thyroid, but that does not mean that you're not having these symptoms, or those symptoms are not important, or those symptoms are not, significantly affecting your life or that they don't need further investigation.
13:03
Sonia Singh MD: And I, I think this is also a general recurring theme with lab testing is when patients go to a doctor clearly feeling unwell and telling them they're feeling unwell.
13:14
Sonia Singh MD: And then tests come back normal.
13:17
Sonia Singh MD: I'm on this mission to convince other doctors that we need to really be loud and clear and say this does not mean it's over and I can do nothing for you because, oftentimes then the answer is still out there.
13:29
Sonia Singh MD: And a lot of times, honestly, I think it lies in lifestyle or something that's going on with the patient that maybe is not even gonna show up on a lab anywhere, right?
13:36
Sonia Singh MD: It's really about talking to that person and understanding more about what they're experiencing and their history and getting a little bit more in depth about what's going on.
13:45
Sonia Singh MD: And so I think this is a really good example where people are aware that, okay, there's these limited labs that I can get at my PCP and oh, they told me I'm normal, and so they're writing me off.
13:55
Sonia Singh MD: And then with the thyroid, it's so easy, like extremely easy to go to another place.
14:01
Sonia Singh MD: And if you are convinced that you have a thyroid issue, if you want a thyroid diagnosis, you can almost find it.
14:06
Sonia Singh MD: Anywhere, like you can find somebody who will check enough things that something will be abnormal and they will say, yes, you do.
14:13
Sonia Singh MD: And so I just think we, we leave these gaps in terms of explanation of things, in terms of validation, and I think, all the pseudoscience and alternative wellness world comes in and fills those gaps.
14:26
Rebecca Berens MD: Yeah.
14:26
Rebecca Berens MD: And I think, like you said, it's, I think the way the healthcare system in particular is structured is such that you only need to see me if there's something wrong.
14:35
Rebecca Berens MD: That's built into the system, right?
14:37
Rebecca Berens MD: Like we have these free annual physicals and that's the one time a year you go and check in unless there's something wrong with you.
14:43
Rebecca Berens MD: And, doesn't even cover asking any questions about anything you might have experienced.
14:47
Rebecca Berens MD: But that's a whole other, that's a whole other podcast.
14:49
Rebecca Berens MD: But you go in and it's okay, do your labs.
14:51
Rebecca Berens MD: If something's wrong, come back, otherwise I don't wanna see you.
14:53
Rebecca Berens MD: Which really is not the way that primary care is designed to work, or at least that we're trained.
15:00
Rebecca Berens MD: I think especially with complicated chronic, multifaceted conditions and symptoms the answer is in the follow-up over time.
15:08
Rebecca Berens MD: The answer is never gonna happen from one lab test.
15:11
Rebecca Berens MD: Like you said, it's super common to have patients that fit the profile of someone with hypothyroidism, but it's very rare that a patient comes in and they have all these things and you check their labs and it's hypothyroidism.
15:21
Rebecca Berens MD: You're like, here's a pill, everything's fixed, and everything's better.
15:23
Rebecca Berens MD: That happens and it's so satisfying when it happens.
15:25
Rebecca Berens MD: Yes.
15:26
Rebecca Berens MD: Yay, we fixed it with this easy, cheap pill.
15:28
Rebecca Berens MD: Yes.
15:28
Rebecca Berens MD: But actually most of the time.
15:31
Rebecca Berens MD: It's complex.
15:32
Rebecca Berens MD: There's multiple things going on, and the answers are gonna come gradually over time in the follow-up.
15:37
Rebecca Berens MD: But, that's difficult and expensive for patients to take time off work to go to much multiple follow-up appointments.
15:44
Rebecca Berens MD: The appointments are not even that long to be having these kinds of conversations at those visits.
15:49
Rebecca Berens MD: And it's a function of the poorly structured healthcare system that it leads itself into screen if it's normal, all right, it's not that important, come back later.
15:59
Rebecca Berens MD: And then it's just like feeding people directly into the arms, open arms of the alternative practitioners who wanna give them answers.
16:07
Rebecca Berens MD: And yeah, it's, obviously you and I do things differently for that reason because we often do find the answers for people, but it's usually not in the first one or two, or even three visits.
16:18
Rebecca Berens MD: It's gradual over time.
16:20
Rebecca Berens MD: Yeah.
16:20
Rebecca Berens MD: And yeah, I think that's like a big function of the weight, just the structure of the healthcare system that feeds into that.
16:25
Sonia Singh MD: So that touches on a really important point.
16:28
Sonia Singh MD: I totally agree.
16:28
Sonia Singh MD: And I think not only is it just like the, not only is it structured in a way that's like you're okay or you're not okay, but it's very disease based or diagnosis based.
16:38
Sonia Singh MD: It's almost like you don't have an opportunity to talk about things or it's okay, you either have a disease or you don't have a disease.
16:44
Sonia Singh MD: If you don't have a disease, you just shouldn't be here.
16:46
Sonia Singh MD: Or what diagnosis code am I billing this for?
16:48
Sonia Singh MD: What is the reason for this visit?
16:50
Sonia Singh MD: But so often in my practice now I'm like, okay, this person is stressed.
16:54
Sonia Singh MD: They don't have anxiety or depression yet.
16:56
Sonia Singh MD: They don't have adjustment disorder.
16:58
Sonia Singh MD: But I can clearly see that this person is stressed and that stress is having an effect on their health and their wellbeing or with nutrition, somebody might have normal cholesterol and normal blood sugar, but they may be really struggling to eat enough vegetables.
17:10
Sonia Singh MD: And that's, it feels like, where, when are you supposed to talk about those things?
17:14
Sonia Singh MD: Or when are you supposed to talk about concerns you have about your health and how to address them before they reach the level of pathology?
17:21
Sonia Singh MD: And I think because it's just such a hassle to get into the doctor anyway, and you get such limited time.
17:27
Sonia Singh MD: We really don't welcome that.
17:28
Sonia Singh MD: Those types of conversations, we make it so hard for people to do that kind of proactive, preventive stuff with us.
17:35
Sonia Singh MD: And I, again, going back to the thyroid, I think people, if you go in with this mindset of I have thyroid disease or I don't have something's wrong with my thyroid, or something is not wrong with my thyroid and your doctor's.
17:43
Sonia Singh MD: No, nothing is wrong with your thyroid and somebody else does this fuller panel and find some little abnormalities here and there.
17:50
Sonia Singh MD: It, as we're gonna learn from our discussion, a lot of times that just has to do with a non thyroidal cause or something else that is not actually thyroid dysfunction.
17:59
Sonia Singh MD: Which may have been addressed by just general advice about how to improve and optimize your health and did not really require all of these other things that now you're being sold and prompted to do so anyway.
18:12
Sonia Singh MD: Yeah, I think all of that, is part of what drives people to seek.
18:17
Sonia Singh MD: Full thyroid panel and to look outside of traditional medicine for this.
18:21
Rebecca Berens MD: Yeah.
18:21
Rebecca Berens MD: So let's talk now about what are the facts?
18:23
Rebecca Berens MD: What is, what are the tests that, the typical thyroid panel or the standard thyroid panel, like what are we testing?
18:29
Rebecca Berens MD: What is that telling us about the thyroid?
18:30
Rebecca Berens MD: And then what are these other tests doing?
18:33
Sonia Singh MD: Yeah.
18:34
Sonia Singh MD: The first thing to say is just a lot of thyroid tests exists, there are a lot of possible things that you can check about a thyroid.
18:42
Sonia Singh MD: And it's funny'cause oftentimes I'm sure you get this, two patients will come in and they'll be like, just check everything.
18:46
Sonia Singh MD: Everything on it.
18:47
Sonia Singh MD: I'm like, you don't know this.
18:48
Sonia Singh MD: The menu of LabCorp is like thousands and thousands.
18:51
Sonia Singh MD: You cannot possibly check everything.
18:53
Sonia Singh MD: Technically does doing more labs give you more information?
18:56
Sonia Singh MD: Yeah, it does give you more information, but the question is just is that information valuable, helpful, actionable?
19:01
Sonia Singh MD: What are we gonna do with that?
19:03
Sonia Singh MD: And does it actually help you at all?
19:05
Sonia Singh MD: A lot of these tests, even in this full thyroid panel, are recommended, or indicated or helpful in certain clinical situations.
19:13
Sonia Singh MD: So under the right circumstances, it absolutely makes sense to check an antibody.
19:16
Sonia Singh MD: It absolutely makes sense to check a total T three or, thyroid stimulating immunoglobulin those are indicated for, they're definitely indicated for certain clinical scenarios.
19:25
Sonia Singh MD: The question is this needed for everybody, for screening?
19:28
Sonia Singh MD: For anybody who's just concerned about, low thyroid function.
19:32
Sonia Singh MD: It is also true that the thyroid is just not a simple organ.
19:35
Sonia Singh MD: It is very complex and influenced by a lot of different factors, and so you can see little fluctuations and variations in some of these tests depending on what's going on with the rest of your health.
19:46
Sonia Singh MD: There may be some information to be gleaned from that.
19:50
Sonia Singh MD: I think it's also true, as we touched upon that, labs don't always tell you the full story about anything, whether it's two labs or 10 labs.
19:57
Sonia Singh MD: It's not the end of the road in terms of understanding one organ's function or an entire person's health or anything.
20:04
Sonia Singh MD: I think.
20:05
Sonia Singh MD: It's important to just acknowledge that, even when you get the appropriate lab tests, it's normal for there to be some unanswered questions and it's very understandable to want to get additional tests to try to fill those gaps.
20:18
Sonia Singh MD: And I think as we were talking about, we in healthcare leave a ton of gaps and so it's a very natural thing to say why don't we just get more information on this if we're concerned about it.
20:29
Sonia Singh MD: So the last point I wanna make in terms of the negative truth is like a more, it's it's something that I've been thinking about a lot lately and actually in terms of, in the context of menopause and perimenopause, which we'll talk about on the next episode hopefully, but.
20:42
Sonia Singh MD: In medicine we're constantly taught don't order a test.
20:45
Sonia Singh MD: That is not gonna change your management.
20:47
Sonia Singh MD: You always wanna ask yourself, okay, why am I checking this?
20:50
Sonia Singh MD: Does it make sense to check it?
20:52
Sonia Singh MD: And how is it gonna change my plan?
20:53
Sonia Singh MD: Because if you're gonna check a test and literally there's nothing to do about it you're not gonna change anything you advise to the patient or anything you recommend or how you treat them.
21:01
Sonia Singh MD: Then in, in our medical training, the guidance is you probably should not do that test.
21:06
Sonia Singh MD: I think what I'm coming to understand now that I've, had the ability to practice a little bit outside of the box is that yes, there's evidence-based guidelines on what tests make sense and what are indicated, and how those should be used to guide treatment.
21:21
Sonia Singh MD: But I think parallel to that, there's this patient experience that's happening where they are trying to understand their own health and their own disease process and their own body and their own pathology and sometimes.
21:32
Sonia Singh MD: Sometimes I think checking one or two additional things to help them develop and flesh out that understanding and, feel more comfortable with the diagnosis and the plan.
21:44
Sonia Singh MD: Sometimes to me that kind of falls into the art of medicine category where, yes, it is not what the guidelines tell me to do, and yes, I should not do it for every single patient and, just, blindly order the same panel for everybody.
21:57
Sonia Singh MD: But maybe in select clinical scenarios, I might choose to do a test or two that I know is not gonna change my management.
22:06
Sonia Singh MD: But has the value of helping the patient come to terms with their diagnosis or lack of diagnosis and kind of understanding their physiology a little bit better?
22:18
Sonia Singh MD: And I think about that a lot more in the context of menopause, but I think it's applicable here too.
22:22
Sonia Singh MD: I don't know what your thoughts are on that.
22:23
Rebecca Berens MD: Yeah, no, I totally agree with that.
22:25
Rebecca Berens MD: I think it's so interesting'cause some part of these guidelines are based on cost, right?
22:31
Rebecca Berens MD: That is one of the things that people are taking into account when they are looking at the data that exists on risk of a test, benefit of a test.
22:42
Rebecca Berens MD: Cost of a test is part of it, right?
22:44
Rebecca Berens MD: Yeah.
22:44
Rebecca Berens MD: And it's so tricky because, in some countries, like where there's universal healthcare, that does dictate what is available to a person, right?
22:52
Rebecca Berens MD: Like they truly may not have the option to have a certain test done if it has not been deemed appropriate by.
23:01
Rebecca Berens MD: The guidelines for that.
23:02
Rebecca Berens MD: And it's not only based on the medical necessity, it's also based on cost benefit.
23:07
Rebecca Berens MD: Yes.
23:08
Rebecca Berens MD: And in the US that's less of it because we don't have a universal healthcare system, but we do have insurance companies dictating what diagnosis codes they think different tests should and should be covered under.
23:19
Rebecca Berens MD: And I think that's where part of the mistrust comes from with patients because they're like, you just don't wanna do this for me because insurance doesn't wanna pay for it or whatever.
23:29
Rebecca Berens MD: But it's but I'll pay.
23:30
Rebecca Berens MD: Yeah.
23:30
Rebecca Berens MD: And that's one of the interesting things about being private now.
23:33
Rebecca Berens MD: You and I both are like, sometimes it's a scenario of a patient who's I want everything done, I'll pay for any of it.
23:39
Rebecca Berens MD: And it's talking them down Hey, too much information is not helpful.
23:42
Rebecca Berens MD: And it's gonna create confusion and anxiety and potentially diagnostic workups that go nowhere that are, potentially risky to you, depending on the situation and what needs to be worked up.
23:52
Rebecca Berens MD: And then also just the time expense and the anxiety brain space expense, right?
23:55
Rebecca Berens MD: We have to, there has to be a limit somewhere.
23:58
Sonia Singh MD: But there
23:58
Rebecca Berens MD: is probably a place for, like you're saying, doing a little bit more testing to help people better understand.
24:05
Rebecca Berens MD: And it might, in my view, it does change management because maybe it doesn't change if I prescribe a medicine to a patient, but maybe it changes that person's motivation to make a certain lifestyle change.
24:18
Rebecca Berens MD: I see this a lot with insulin resistance.
24:19
Rebecca Berens MD: Like I do routinely check insulin levels now on my patients which I did never did in employee practice before.
24:27
Rebecca Berens MD: And part of that was like, I think we've understood a lot more about testing for that now than we did in the past.
24:31
Rebecca Berens MD: But it, but I think it is very motivating to a person to understand My blood sugar is normal.
24:37
Rebecca Berens MD: My cholesterol's normal now, but I know I have this family history of diabetes and hey, I do have some insulin resistance.
24:43
Rebecca Berens MD: So Maybe now is a time for me to like really prioritize making some of these changes that I've felt like I had more time to deal with, and so I think that's again, there, I think there has to be a line somewhere.
24:55
Rebecca Berens MD: Yeah.
24:56
Rebecca Berens MD: But I do think that, and I would argue that it does change management and in thyroid it's not quite the same.
25:01
Sonia Singh MD: Yeah.
25:01
Sonia Singh MD: But,
25:02
Rebecca Berens MD: We'll get into this when we talk more about the physiology, I quite often find it very useful to check more thyroid tests to help people believe that they're undereating uhhuh.
25:12
Rebecca Berens MD: Yeah.
25:13
Rebecca Berens MD: You told me.
25:13
Rebecca Berens MD: Which, we'll get into this, but it is sometimes very difficult to convince people that they're undereating, but.
25:20
Rebecca Berens MD: Their T three conversion will show you.
25:23
Rebecca Berens MD: So that's, something that we can talk about as we get into physiology, but I think, to your point about does it change management, I would argue it does on the patient end, maybe not on the physician end.
25:32
Sonia Singh MD: Yeah, that's, no, that's a really good point.
25:35
Sonia Singh MD: And I think you're absolutely right.
25:38
Sonia Singh MD: For instance, checking, checking the insulin level when the A1C is normal, it's I think someone might argue, yeah, but you're giving them the same advice you would give, somebody you were just generally advising to eat healthier.
25:49
Sonia Singh MD: It's not changing your advice, it's not prompting you to prescribe them anything or do further testing.
25:54
Sonia Singh MD: So what is the point?
25:55
Sonia Singh MD: But maybe it's just motivation, maybe it is just something else that, the patient can see something that feels concrete and objective that, motivates them to change and to track their improvement.
26:04
Sonia Singh MD: So yeah, I think that's a great point.
26:07
Sonia Singh MD: So next we're gonna cover a little bit about what are the facts about thyroid testing?
26:12
Sonia Singh MD: And we're gonna, I'm gonna try to discuss it with some context and some nuances.
26:15
Sonia Singh MD: And I wanna preface this by saying I am not an endocrinologist.
26:18
Sonia Singh MD: You are not an endocrinologist.
26:20
Sonia Singh MD: There are people who are much more expert on all of this than I am.
26:22
Sonia Singh MD: And honestly, this episode is a little bit of a high view broad overview of this topic.
26:28
Sonia Singh MD: And you could go way deeper on each of these things.
26:30
Sonia Singh MD: But I'm gonna try to give a broad strokes overview here.
26:33
Sonia Singh MD: The thyroid is an endocrine gland.
26:35
Sonia Singh MD: It sits at the base of your neck.
26:36
Sonia Singh MD: It produces thyroid hormone, which controls and influences all these different processes in your body.
26:41
Sonia Singh MD: TSH, which is thyroid stimulating hormone is actually produced by the pituitary glands.
26:46
Sonia Singh MD: It's not even, produced by the thyroid.
26:48
Sonia Singh MD: The pituitary gland is in your brain and it basically tells the thyroid to make thyroid hormone.
26:53
Sonia Singh MD: So the thyroid is mostly making T four.
26:55
Sonia Singh MD: It's also making some T three and T three is really the thyroid hormone.
26:59
Sonia Singh MD: And then T four gets converted to T three according to your body's needs.
27:03
Sonia Singh MD: And importantly, that is happening mostly at the tissue level.
27:07
Sonia Singh MD: And then there's also something called reverse T three, which is an inactive form of T three that T four can be converted into.
27:15
Sonia Singh MD: We'll talk more about whether that's meaningful and worth checking, and then there's gonna be total and free assays for both.
27:23
Sonia Singh MD: T three and T four and total just means you're counting the amount that's bound to something.
27:27
Sonia Singh MD: So your thyroid can be underactive, overactive, or can have some other more rarer dysfunctions.
27:34
Sonia Singh MD: In this conversation, like I talked about at the beginning, we're gonna focus a little bit on hypothyroidism and Hashimoto, since that's I think, what gets the most play on social media and what's the most commonly seen.
27:44
Sonia Singh MD: So in hypothyroidism, your thyroid is a little underactive and sluggish.
27:49
Sonia Singh MD: So the brain, the way I describe it to my patients is usually like your brain is having to yell at the thyroid to get itself in order and make more thyroid hormone.
27:57
Sonia Singh MD: And so in hypothyroidism, the TSH is actually going to be high and the free Z four will be low.
28:03
Sonia Singh MD: And then conversely, in hyperthyroidism, typically you're gonna see that the thyroid is cranking up, cranking out too much thyroid hormone, and that's gonna actually suppress the TSH levels.
28:11
Sonia Singh MD: So it's gonna be low.
28:13
Sonia Singh MD: And then your T three and T four may be high.
28:16
Sonia Singh MD: And then there's subclinical versions of both hypo and hyperthyroidism.
28:22
Sonia Singh MD: So in the subclinical version, the TSH has become abnormal, but the free T four is still normal.
28:29
Sonia Singh MD: And I think there's a lot of, misconceptions and miscommunication happening around that, those subclinical versions, which we'll get into a little bit.
28:37
Sonia Singh MD: So before I go forward with any more physiology and talking about the specific tests, I wanna point out that in the alternative medicine world, something that I've observed really often is there's a lot of focus on talking about the physiology.
28:51
Sonia Singh MD: And honestly, they do a much better job of that than we do in medicine.
28:56
Sonia Singh MD: I think often because of time pressure or various other reasons.
29:02
Sonia Singh MD: In your traditional doctor's office, sometimes you are not really getting a full explanation of what the tests are and what they mean and how they relate to your thyroid.
29:10
Sonia Singh MD: Like it's a little counterintuitive that high TSH is hypo, associated with hypothyroid or lower thyroid function.
29:16
Sonia Singh MD: And sometimes I find even that most basic explanation a patient has not gotten and they're like looking at their results and they're like, I don't know.
29:22
Sonia Singh MD: They told me I was high.
29:23
Sonia Singh MD: They told me I was low.
29:24
Sonia Singh MD: I can't remember.
29:24
Sonia Singh MD: They've clearly had such little.
29:26
Sonia Singh MD: Good communication about what these tests mean and what they're checking.
29:30
Sonia Singh MD: So I noticed in the alternative world, there's a lot of talk about physiology, and I think that's super attractive and compelling to people who are trying to understand what in the heck is going on in their bodies.
29:40
Sonia Singh MD: And I think what often happens is they move very quickly from going through the physiology and then start drawing conclusions about why is the TSH the only test that, that's not even a thyroid, it's coming from the brain.
29:51
Sonia Singh MD: T three is your active thyroid hormone.
29:53
Sonia Singh MD: So why would you not be checking that and wouldn't you wanna know if you have too much reverse T three or there's not enough conversion happening from T four to T three?
30:02
Sonia Singh MD: And so I think when you someone explains the physiology in depth to you, it's.
30:07
Sonia Singh MD: So natural to then start having these questions and thinking gosh, there's all these other hormones involved, like why would my doctor not check those?
30:14
Sonia Singh MD: And then I think they're very quick in that world to say you can check them.
30:17
Sonia Singh MD: There's all these other things, like why would you not check these?
30:21
Sonia Singh MD: And I think the point I wanna remind people of is that.
30:24
Sonia Singh MD: The physiology is really the starting point for us in medicine that is where you develop your theories and hypotheses about what might be worth checking and what might make sense to intervene upon and where we might have therapeutic interventions.
30:37
Sonia Singh MD: And it's really just the starting point and then, to decide.
30:42
Sonia Singh MD: What testing makes sense and to interpret those tests and decide how they influence management.
30:47
Sonia Singh MD: You can't just look at physiology or just know physiology really well.
30:50
Sonia Singh MD: It doesn't matter how many receptors and enzymes you have memorized, you need to understand lab science and the specific assays and the reliability, accuracy, validity of those tests.
31:00
Sonia Singh MD: And you need to understand clinical research and clinical data and what do these tests actually mean for an actual human being and for management of disease and diagnosis of disease.
31:10
Sonia Singh MD: And those second two parts are almost never part of the equation.
31:15
Sonia Singh MD: I find that it goes straight from really detailed, really in depth discussion of physiology and receptors and enzymes and tissues and all this other stuff.
31:22
Sonia Singh MD: And then quickly goes to and therefore these are the tests that you need.
31:25
Sonia Singh MD: And, how do we make those tests look normal?
31:28
Sonia Singh MD: And that's the goal.
31:30
Sonia Singh MD: And I wanna put it out there because I think.
31:32
Sonia Singh MD: I see this also, I studied nutrition and so I've seen a lot of nutrition related misinformation out there.
31:39
Sonia Singh MD: And this is a very common thing that you see there too, where you know how a certain vitamin or mineral or nutrient, works in the body, you know what function it has in, in, in certain, in some physiologic pathway.
31:53
Sonia Singh MD: And maybe you even have, data that people who have higher levels of that particular vitamin or mineral have better outcomes and have less cancer and have more heart disease.
32:02
Sonia Singh MD: But it's so common that we cannot measure that thing very accurately or we don't have a reliable way to measure that thing.
32:08
Sonia Singh MD: Or even if we can measure that thing, that we isolate it, we put it in a pill, we give it to people, we raise their levels, and what do you know?
32:15
Sonia Singh MD: The outcome is no different.
32:16
Sonia Singh MD: They don't really have any benefit from it.
32:17
Sonia Singh MD: And they don't have the same things that we saw in the big epidemiologic studies, or sometimes they have adverse outcomes that we can't even explain.
32:25
Sonia Singh MD: And that is extremely common in the world of nutrition and supplements.
32:29
Sonia Singh MD: And so anyway, I wanted to drive that point home.
32:32
Sonia Singh MD: 'cause I think it comes back over and over again.
32:35
Rebecca Berens MD: Yeah.
32:35
Rebecca Berens MD: And I think it appeals to the feeling that people have when they go to their doctor of I don't have all the information.
32:41
Rebecca Berens MD: There's something you're not telling me.
32:42
Rebecca Berens MD: Yes.
32:42
Rebecca Berens MD: And they're like, let me lay it out for you.
32:45
Rebecca Berens MD: But even the alternative practitioner, like laying it out for them, like probably is missing a lot of these details.
32:50
Rebecca Berens MD: Yeah.
32:50
Rebecca Berens MD: And it is so hard.
32:52
Rebecca Berens MD: We went to school for a very long time to learn all of this stuff, right?
32:55
Rebecca Berens MD: It is very hard to summarize all of that in a quick blog post or a two minute reel.
33:00
Rebecca Berens MD: It's just not, or 30 minute podcast, and like it's, I think the it's appealing to that desire that people want for more information and more understanding that the traditional medicine has been historically very bad at communicating.
33:14
Rebecca Berens MD: Yeah.
33:14
Rebecca Berens MD: And that's part of obviously our goal with the podcast is to try to improve the communication, but even then it is really challenging.
33:21
Rebecca Berens MD: And but I think it just, that's what opens the door for people to.
33:25
Rebecca Berens MD: To get the information from someone else who is willing to give it to them.
33:29
Sonia Singh MD: Yeah.
33:29
Sonia Singh MD: And I like what you said about it feeds into this idea that you're hiding something or that you don't want them to know something, and it's so funny'cause on the surface it really looks like these people who are explaining all these detailed mechanisms, really know their stuff and they've done this really deep dive.
33:43
Sonia Singh MD: But the reality is that type of mechanistic thinking is often really an oversimplification of clinical medicine generally.
33:51
Sonia Singh MD: And just a general misunderstanding of how science works and how we make decisions about what we do in human bodies and to people, real human patients.
34:01
Sonia Singh MD: Okay.
34:01
Sonia Singh MD: So I wanted to talk a little bit more about what that lab research and clinical research tells us about thyroid testing.
34:09
Sonia Singh MD: So we'll start with ts H and we'll go through each of them.
34:11
Sonia Singh MD: TSH is the most sensitive and specific marker for detecting primary hypothyroidism.
34:16
Sonia Singh MD: So if you are concerned about low thyroid function, that is what you are going to the doctor for.
34:20
Sonia Singh MD: TSH is going to be your most valuable test.
34:22
Sonia Singh MD: So sensitive means that it's going to pick up the most true cases of hypothyroidism in a group of people compared to the other tests.
34:30
Sonia Singh MD: And specific means that if this test is abnormal.
34:35
Sonia Singh MD: Typically it is going to be because of thi low thyroid function as opposed to some other cause that is, causing that abnormality.
34:43
Sonia Singh MD: In medical school and biostats and epidemiology, we learn that, sensitivity of a test is really good for ruling something out.
34:50
Sonia Singh MD: So if you te check that test and it's normal, you can feel pretty confident that person does not have that disease that you're looking for.
34:57
Sonia Singh MD: And so the sensitivity of TSH for detecting primary hypothyroidism is 98%.
35:03
Sonia Singh MD: So you would miss like 2% of cases if you were just relying on the TSH.
35:07
Sonia Singh MD: But as far as lab testing goes, and also people forget that lab testing is fallible in itself and is not always right.
35:14
Sonia Singh MD: But as far as lab testing goes in medicine that is pretty darn good.
35:19
Sonia Singh MD: So it is super sensitive, really good for ruling out thyroid dysfunction and that is why so many doctors.
35:24
Sonia Singh MD: Start with the TSH as the basic screening test for thyroid disease.
35:28
Sonia Singh MD: So the American Thyroid Association and the American Association of Clinical Endocrinology, which are the two big societies that kind of make recommendations around the thyroid.
35:36
Sonia Singh MD: Recommend checking TSH only and then if abnormal, checking a free T four as the initial evaluation for hypothyroidism, and I do this in practice and I'm sure you do this too, is.
35:48
Sonia Singh MD: Luckily we have these tests that are TSH reflex to free T four, which means they're gonna run a TSH on your labs.
35:55
Sonia Singh MD: If that is abnormal, they will use the same sample and run a free T four so you don't have to go back physically and get another draw.
36:01
Sonia Singh MD: 'cause I always felt like that was the worst part of doing the two step process that is recommended.
36:05
Sonia Singh MD: And now we have a way around that.
36:08
Sonia Singh MD: So I wanted to specifically say that these big associations have that recommendation because I think there's a big assumption among people who are getting fed a lot of this information that if they go to the doctor.
36:19
Sonia Singh MD: And they want their thyroid evaluated, and the doctor has done a TSH and a free T four.
36:25
Sonia Singh MD: That does not mean that they don't believe you or that they're trying to brush you off or that they're just misinformed.
36:32
Sonia Singh MD: They're following the guidelines of the two biggest societies that, are composed of the world's experts on these topics.
36:38
Sonia Singh MD: So they're following evidence-based guidelines.
36:42
Sonia Singh MD: Important note though is I'm focused here on hi hypothyroidism, but if you are suspecting hyperthyroidism, the initial recommendation is to check a tsh, a free C four, and a total T three, but still not the full thyroid panel.
36:55
Sonia Singh MD: Okay, so moving on to T three.
36:57
Sonia Singh MD: The first question to ask is this lab helpful to check and can we check it accurately?
37:02
Sonia Singh MD: And, or is this result meaningful?
37:04
Sonia Singh MD: So for somebody who has suspected hypothyroidism, but is not on any treatment yet, T three tends to not be helpful for a variety of reasons.
37:12
Sonia Singh MD: One is just.
37:14
Sonia Singh MD: A function of the assay itself.
37:15
Sonia Singh MD: It's just not as good of a test and it's not as accurate as our T four testing.
37:20
Sonia Singh MD: And so that's part of the reason we're not checking it as often as, we check the T four.
37:26
Sonia Singh MD: Secondly, a lot of the conversion of the T four to T three is happening at the tissue level.
37:31
Sonia Singh MD: So the circulating T three oftentimes does not change until quite far along in the disease, in which case you would already be seeing evidence of the disease in the TSH and the free T four levels.
37:42
Sonia Singh MD: So even though, it's the active thyroid hormone, which seems like, gosh, wouldn't that be the most important, test to check in clinical practice for someone with suspected hypothyroidism?
37:53
Sonia Singh MD: It's not, it doesn't end up being that valuable.
37:56
Sonia Singh MD: Now that's not the case for people who are already on treatment.
37:59
Sonia Singh MD: So there's a lot of other clinical scenarios in which you've.
38:01
Sonia Singh MD: Would want to check the T three, but just for somebody who's coming in and saying, I'm concerned that my thyroid function is low, T three is not something that is likely to be helpful in that initial evaluation.
38:12
Sonia Singh MD: Then there's the question of conversion.
38:15
Sonia Singh MD: So a lot of people will say theoretically, couldn't you have you, maybe you're in that 2% with the normal TSH and maybe you have a normal free T four, but you are not converting your T four to T three.
38:26
Sonia Singh MD: So the amount of active thyroid hormone that your tissues are actually, receiving is low.
38:31
Sonia Singh MD: And you, that's why you have all the symptoms of hypothyroidism.
38:33
Sonia Singh MD: So this is possible, and you know this, the way I learned this was this is mostly gonna be seen in the context of very severe illness severe malnutrition, certain medications, and then there are, genetic.
38:47
Sonia Singh MD: Enzyme deficiencies where you actually cannot do that conversion.
38:50
Sonia Singh MD: But those are extremely rare.
38:52
Sonia Singh MD: So I actually learned this in medical school as oh, this is such a rare thing to see.
38:56
Sonia Singh MD: That's why we don't check it.
38:57
Sonia Singh MD: And you actually taught me of a clinical scenario in which it may actually be helpful to check.
39:03
Sonia Singh MD: So I'm gonna let you share it.
39:05
Rebecca Berens MD: Yeah.
39:05
Rebecca Berens MD: So I think this is, like I said, is another situation of people requiring data, but this is a common thing that I personally see in patients with eating disorders who are primarily restricting for whatever type of eating disorder they may have, if it's a lot of restriction and they're therefore malnourished.
39:24
Rebecca Berens MD: Yep.
39:24
Rebecca Berens MD: One of the ways that our body conserves energy when we are chronically, not receiving adequate calories, is by slowing down.
39:34
Rebecca Berens MD: Energy consumption throughout the body.
39:36
Rebecca Berens MD: And one of the most efficient ways to do that is to slow down thyroid conversion.
39:40
Rebecca Berens MD: Because the thyroid ramps up and down lots of different body systems.
39:44
Rebecca Berens MD: Yeah.
39:44
Rebecca Berens MD: So if you slow down the conversion of free T four to T three, you are going to slow down a lot of stuff at the same time.
39:51
Rebecca Berens MD: Yeah.
39:51
Rebecca Berens MD: And so this is very something that I very often see.
39:54
Rebecca Berens MD: And it is amazing how someone who is not, maybe receptive or believing that what they're eating is not enough.
40:03
Rebecca Berens MD: And which is common, people who have eating disorders often are not.
40:06
Rebecca Berens MD: Aware, and they're in a lot of denial.
40:08
Rebecca Berens MD: There's a lot of stigma around it.
40:09
Rebecca Berens MD: It, there's a lot of complicated reasons why someone might not believe what you're telling them when you're worried about malnutrition.
40:16
Rebecca Berens MD: But this is a very, again, just to drive from the point of once they see the data, it's hard to ignore.
40:21
Rebecca Berens MD: This is not working.
40:22
Rebecca Berens MD: Like your body's actually not producing a hormone that it needs because it is trying to conserve energy.
40:28
Rebecca Berens MD: So this is something that, that we see.
40:30
Rebecca Berens MD: But again, this does not diagnose a thyroid problem, right?
40:34
Rebecca Berens MD: This diagnosis, a chronic malnutrition or other sort of severe illness problem.
40:39
Rebecca Berens MD: And I think that's where the misunderstanding is.
40:43
Rebecca Berens MD: You still don't have a thyroid problem just because the thyroid test is abnormal, right?
40:47
Rebecca Berens MD: Your thyroid's fine.
40:49
Rebecca Berens MD: It's a non thyroidal illness that's causing this.
40:51
Rebecca Berens MD: And that's where people get so upset about oh, they didn't really check my thyroid.
40:54
Rebecca Berens MD: I'm like, they did.
40:55
Rebecca Berens MD: Your thyroid does work.
40:56
Sonia Singh MD: Yeah.
40:57
Rebecca Berens MD: There other things going on that are causing you to feel that way?
41:00
Rebecca Berens MD: But your thyroid itself is actually working, and so thyroid hormone is not the way to treat that problem.
41:05
Rebecca Berens MD: I could give you tons of thyroid hormone if you're not gonna convert it, what's the point?
41:09
Rebecca Berens MD: But the point is, treat the non thyroidal illness.
41:12
Rebecca Berens MD: And that's where I think these alternative practitioners they're also not diagnosing a thyroid problem if they're diagnosing anything, but even what they tell you, they're just giving you supplements or they're giving you like they're giving you other things, they're still not treating a thyroid problem.
41:25
Rebecca Berens MD: And so it's not a thyroid problem just because a thyroid test is abnormal.
41:29
Rebecca Berens MD: But it is useful information to understand your symptoms, but it's still not a thyroid problem.
41:33
Sonia Singh MD: I feel like I have seen people with, just.
41:36
Sonia Singh MD: A literally a random aberration of one of the thyroid labs get put on levothyroxine or get put on, armor thyroid or Antithyroid or something.
41:45
Sonia Singh MD: Oh, yeah, there's those, I forgot.
41:46
Sonia Singh MD: They can't be diagnosed with thyroid illness and especially, I guess that's true.
41:49
Sonia Singh MD: Hopefully, especially if you were anchored to the diagnosis and you go to them and you were convinced that you had it, and then something comes abnormal and they are, again, not really qualified to interpret those tests easily.
42:02
Sonia Singh MD: They can put you on something.
42:03
Sonia Singh MD: Hopefully they're also not
42:04
Rebecca Berens MD: able to write a prescription.
42:05
Rebecca Berens MD: But who knows?
42:06
Rebecca Berens MD: I guess there's interesting setups that people have, but yes, certainly in that scenario, thyroid hormone is absolutely not the right thing to do.
42:14
Rebecca Berens MD: Yeah.
42:14
Rebecca Berens MD: Because either you worsen the malnutrition by, like avoiding the body, being able to slow things down and conserve energy by ramping up thyroid hormone.
42:24
Rebecca Berens MD: Or nothing happens and it doesn't change anything'cause it just doesn't convert it.
42:28
Rebecca Berens MD: But either case is.
42:29
Rebecca Berens MD: Not helpful.
42:31
Rebecca Berens MD: You haven't treated the problem right.
42:32
Sonia Singh MD: And the argument, the argument against checking the T three for the reason that you just said would be like you don't need that T three to know that they're malnourished.
42:40
Sonia Singh MD: I don't are telling you, already.
42:43
Sonia Singh MD: But as we were talking about before, it's part of maybe this art of medicine category of this person may benefit from seeing this data and knowing that there's consequences to, the level of restriction that they're currently doing and think is okay.
42:57
Sonia Singh MD: So anyway, I think that's a really interesting example and you taught me about that.
43:01
Sonia Singh MD: All so Let's talk about reverse C3.
43:03
Sonia Singh MD: So I feel like reverse T three sounds like very fancy and people are always like, oh, but what about my reverse T three?
43:09
Sonia Singh MD: It's really just like a bust of a test, it's not very helpful.
43:12
Sonia Singh MD: So the American Thyroid Association.
43:14
Sonia Singh MD: Has published a lot of reviews on this, and basically they emphasize that reverse T three testing is really not indicated for initial assessment of any thyroid dysfunction.
43:22
Sonia Singh MD: It doesn't improve diagnostic accuracy.
43:24
Sonia Singh MD: In addition to the other tests that we've already talked about, it's not recommended by really any clinical guidelines.
43:30
Sonia Singh MD: Mainly because when it is altered or abnormal, it's typically from non thyroidal illness.
43:35
Sonia Singh MD: So it's really not evaluating the thyroid very meaningfully.
43:39
Sonia Singh MD: And so I wanted to take a moment to talk about this and we're touching on it by talking about malnutrition.
43:43
Sonia Singh MD: There's something called thyroid six syndrome in which basically some thyroid levels can be abnormal, but it's not due to primary thyroidal illness.
43:53
Sonia Singh MD: It's due to some other illness that's causing those aberrations.
43:56
Sonia Singh MD: And the classic things that, we're taught to think about is severe illness, starvation, malnutrition, sepsis, trauma, major surgery.
44:03
Sonia Singh MD: Not I got stressed out or I had a bad cold And what I have seen, and actually I have an entire highlight on my Instagram my, my Instagram that's been neglected for many months.
44:13
Sonia Singh MD: But I have a highlight saved on there that's called thyroid.
44:16
Sonia Singh MD: And I actually went through a bunch of studies that got cited by a thyroid expert who basically was arguing that all these levels of tests that are not recommended to be checked by the guidelines and that most doctors are not checking or repeatedly checking are actually associated with all these different clinical manifestations and long-term outcomes.
44:39
Sonia Singh MD: And if you look at a lot of the studies she cited in that they're actually referring to people with thyroid six syndrome.
44:47
Sonia Singh MD: And a lot of them are very sick.
44:48
Sonia Singh MD: Like the studies are in ICU patients or in.
44:52
Sonia Singh MD: Diseased monkey brains,, she's taking conclusions from these studies about like cognitive decline associated with certain antibodies, TPO antibodies and applying them to a person who's walking and talking and has some brain fog and some fatigue when the study was done in critically ill patients who are intubated in ICU.
45:13
Sonia Singh MD: I think this whole category of of thyroid six syndrome gets manipulated and misunderstood and studies about this get applied to, like I said, just people who are walking and talking and that really, the data from that study is not generalizable or applicable to
45:30
Rebecca Berens MD: Yeah, and that's, we've talked about this before, but like whenever you're talking about a study, the population that you studied, if that population does not look like the population you're applying it to, how relevant is that information in general?
45:40
Rebecca Berens MD: And that's why, having a varied number of studies repeated on different populations, showing the same conclusion, or a randomized control trial that includes a lot of different people of different demographics and in different parts of the world over and over again, repeating and showing the same conclusions is so much more powerful than like a couple single studies that are cited here and there.
46:01
Rebecca Berens MD: And that's, the whole crux of evidence-based medicine is being able to parse out all those details, not just throwing up a link from PubMed and be like, see there's a study on it.
46:10
Rebecca Berens MD: It's not quite the same.
46:11
Rebecca Berens MD: Yes,
46:12
Sonia Singh MD: yes.
46:13
Sonia Singh MD: Yeah.
46:13
Sonia Singh MD: So if you wanna deeper dive, if you're just like, no, but I've seen, people have told me there is data for this, you can watch that set of highlights because I went through every single PubMed article, I think it was five or six PubMed articles that she linked and I read every single one.
46:27
Sonia Singh MD: And I talked about why they were not really proving the point that she was trying to make.
46:30
Sonia Singh MD: Next I wanted to talk about anti TPO antibodies.
46:33
Sonia Singh MD: This is a big hot button topic, and I know we're gonna get some feisty comments about this, but, so the most common cause of hypothyroidism is Hashimoto's thyroiditis, which is an autoimmune condition in which you have antibodies that are attacking your own thyroid gland, and over time can affect its functioning.
46:51
Sonia Singh MD: And the most common antibody that's detected in Hashimoto's patients is the anti TPO antibody.
46:55
Sonia Singh MD: And the second most common are the thyroglobulin antibodies, but those are a lot less common.
47:00
Sonia Singh MD: So there's specific clinical scenarios in which the American Association of Clinical Endocrinology and the American Thyroid Association actually think this is warranted to check.
47:09
Sonia Singh MD: And those are in patients with subclinical hypothyroidism.
47:12
Sonia Singh MD: So that scenario in which the TSH was high, but the free T four was normal checking antibodies can help you determine how high a risk that patient has of progressing to overt hypothyroidism versus maybe just normalizing on the next test.
47:27
Sonia Singh MD: And the risk is twice as high if somebody has antibodies present versus if they don't.
47:32
Sonia Singh MD: So that would just prompt you to maybe, monitor their thyroid a little bit more frequently.
47:36
Sonia Singh MD: And by frequently, the guidelines are like six to 12 months.
47:39
Sonia Singh MD: So it's really not this is dramatically changing how often you're getting labs.
47:42
Sonia Singh MD: 'cause a lot of people are getting these labs once a year anyway.
47:45
Sonia Singh MD: And the other scenario in which you may check an antibody level is when somebody has a goiter.
47:50
Sonia Singh MD: In that case it can help you determine if someone has an autoimmune thyroiditis or if they may have a multinodular go.
47:55
Sonia Singh MD: In that case, you're probably also doing some imaging.
47:57
Sonia Singh MD: In those specific contexts it is maybe valuable.
48:00
Sonia Singh MD: It can be checked to determine the cause of someone's primary hypothyroidism.
48:06
Sonia Singh MD: But they actually advise against checking it as part of a general evaluation for suspected hypothyroidism.
48:11
Sonia Singh MD: And certainly not checking in the general population because, and actually I didn't know this until I looked it up, but 20% of the general population has an anti TPO antibody.
48:21
Sonia Singh MD: If we're referring to that entire population is having Hashimoto's, that's a lot of people.
48:26
Sonia Singh MD: And the rate of progression of somebody with antibodies to overt hypothyroidism, so like something that must be treated is two to 4%.
48:36
Sonia Singh MD: So it's not like I, I think a lot of patients have the perception when they get diagnosed with subclinical hypothyroidism or they get told they have these antibodies.
48:45
Sonia Singh MD: They have this, like my patient, I think had this feeling of oh my God, I've gotta get to work.
48:49
Sonia Singh MD: 'cause like I'm gonna, I'm on this fast train to with thyroidism, I'm probably gonna have it within, the next couple of years.
48:54
Sonia Singh MD: And it's important to note that doesn't actually happen.
48:57
Sonia Singh MD: It's certainly not like a you are going to have this problem, imminently.
49:00
Sonia Singh MD: Yeah.
49:01
Rebecca Berens MD: And this is actually something that I personally experienced.
49:04
Rebecca Berens MD: Where, so my mom has hypothyroidism and has Hashimoto's.
49:07
Rebecca Berens MD: And when I was trying to have my first baby, and I didn't immediately get pregnant in three months, I was freaking out as you do.
49:14
Rebecca Berens MD: And so I was like I haven't had a physical in a while.
49:17
Rebecca Berens MD: Let me go just make sure everything's fine.
49:18
Rebecca Berens MD: My mom had at that point recently been diagnosed with hypothyroidism.
49:22
Rebecca Berens MD: And so I was like, oh, maybe I have it too.
49:23
Rebecca Berens MD: Maybe that's why I can't get pregnant.
49:25
Rebecca Berens MD: So I went to my PCP at the time and they.
49:31
Rebecca Berens MD: Talk to me.
49:31
Rebecca Berens MD: And this is the struggle of being a doctor patient.
49:34
Rebecca Berens MD: I told them the reason that I was concerned and I think they thought I wanted them to check if I had Hashimoto's.
49:41
Rebecca Berens MD: I really just wanted to check my thyroid.
49:42
Rebecca Berens MD: But anyway, they ordered the antibodies along with the TSH and free T four.
49:45
Rebecca Berens MD: And my TSH and free T four were totally normal, but I did have high levels of Hashimoto antibodies, which is not surprising'cause my mom has it and it's, it's genetic and anyway but from that day on, anytime I feel anything, I'm like, oh, this is it.
50:00
Rebecca Berens MD: It must be my thyroid's finally gone.
50:03
Rebecca Berens MD: Yeah.
50:04
Rebecca Berens MD: And it's even though, because obviously I do have higher risk of developing hypo hypothyroidism, and I know that, but it's amazing how, despite my knowledge of that doesn't mean every little symptom that you have is hypothyroidism.
50:14
Rebecca Berens MD: That is immediately where my brain goes.
50:16
Rebecca Berens MD: Yeah.
50:16
Rebecca Berens MD: But I can only see that it's happened to me.
50:19
Rebecca Berens MD: Even with all of the knowledge that I have, any patient would.
50:23
Rebecca Berens MD: Logically come to that conclusion.
50:25
Rebecca Berens MD: And I think it's also there's more of a push now of like preventive medicine and if you do stuff now, are proactive, you can prevent anything truthfully.
50:34
Rebecca Berens MD: I don't, I've never, at least I've looked, I've never seen any credible evidence that there's anything you can do to reduce your risk of progression to hypothyroidism when you have Hashimoto's.
50:44
Rebecca Berens MD: I'm curious if you found anything in your work because, no, I'm personally interested to know, but no, I've never found it and I've looked up several times.
50:51
Sonia Singh MD: I think, like you said, there's so much temptation to believe that okay, so if my thyroid is starting to be abnormal and I have these antibodies and that is the cause of my thyroid being abnormal, if I just get these antibody levels down, that should help.
51:07
Sonia Singh MD: Why would that not make sense?
51:09
Sonia Singh MD: Why would I not wanna do that?
51:10
Sonia Singh MD: The other thing that I wanted to point out before we talk about, how to do that, but in the alternative world, it's very common to have serial monitoring of your antibody levels and to target reduction of those levels as one of the treatment goals.
51:24
Sonia Singh MD: But that is completely contrary to what is recommended by our, expert guidelines.
51:28
Sonia Singh MD: So both the American Thyroid Association and the American Association of Clinical Endo guidelines explicitly state that repeated TPO antibody testing does not contribute to the management of subclinical hypothyroidism is not recommended and is not influence, risk, stratification, diagnosis, or progression.
51:44
Sonia Singh MD: Hypothyroidism.
51:45
Sonia Singh MD: So not only are they saying this does not guide your treatment.
51:47
Sonia Singh MD: They're like, it doesn't tell you anything about whether this person is gonna be symptomatic or whether they're gonna progress.
51:53
Sonia Singh MD: Again, a lot of people will cite a lot of studies that are probably not proving this point, but they will pretend that they're proving this point in a way that's just not generalizable to the people that they're trained to apply it to.
52:05
Sonia Singh MD: I can see why logically that feels so much more compelling than going to a doctor that's I don't know why you have this, we can't change it.
52:14
Sonia Singh MD: I don't know why you have this.
52:16
Sonia Singh MD: You may progress to hypothyroidism, you may not.
52:19
Sonia Singh MD: When you do, you can take a medicine and that is all you're getting.
52:23
Sonia Singh MD: It's so unsatisfying.
52:24
Sonia Singh MD: You're like, it's great sounds, it's totally unsatisfying, it's totally unsatisfying.
52:28
Sonia Singh MD: Meanwhile, you go to somebody else who's these are these levels.
52:31
Sonia Singh MD: We can track them.
52:32
Sonia Singh MD: I'm gonna tell you these supplements to take and these things to do with your diet and these other things you can do with your lifestyle that's gonna lower these levels and that's gonna be better.
52:39
Sonia Singh MD: And I remember in my first session with that patient I talked about at the beginning of the episode, she was really fixated on her levels.
52:45
Sonia Singh MD: And she had gone and done, I guess I'll give you the update on her.
52:48
Sonia Singh MD: She had gone and done all of the things, she was trying so hard.
52:51
Sonia Singh MD: She has little kids with their own dietary stuff.
52:54
Sonia Singh MD: So she was just like, it's been so hard trying to follow this.
52:56
Sonia Singh MD: I'm trying to do the supplements I'm trying to do.
52:58
Sonia Singh MD: I felt like she was just spending so much time and energy and money trying to do this, and her antibody levels were just bouncing around.
53:05
Sonia Singh MD: They didn't, there was no clear trend.
53:07
Sonia Singh MD: They were just bouncing all over the place.
53:09
Sonia Singh MD: And I think by the time I saw her, she did have overt hypothyroidism and it had actually been like, her TSH had been abnormal at that point for several months.
53:20
Sonia Singh MD: And I remember just thinking what?
53:22
Sonia Singh MD: You got diagnosed with this like a year and a half ago, once you make a diagnosis, this is a very treatable condition, and it just made me so sad that she had really tortured herself.
53:32
Sonia Singh MD: And like I said, I don't think she felt like she was torturing herself.
53:34
Sonia Singh MD: She felt like it was actually very helpful and validating and empowering when she started on this journey of trying to fix her thyroid.
53:41
Sonia Singh MD: But ultimately, all of the things she was doing were not very evidence-based and they did not really seem to make a difference.
53:49
Sonia Singh MD: And so ultimately She went on the medicine and now her levels are normal.
53:53
Sonia Singh MD: Now I wanna make this point because I think there's this perception that the doctor just wants to give you the pill or the doctor's not interested in the root cause, or the doctor's not interested in looking further.
54:04
Sonia Singh MD: They just are like, take the medicine or don't take the medicine.
54:06
Sonia Singh MD: Those are your only options.
54:08
Sonia Singh MD: And I think this idea that.
54:11
Sonia Singh MD: A patient or people in general, non-medical people are really interested in the root cause, but somehow doctors just don't care and have not thought about it and don't have any motivation to address the root cause.
54:22
Sonia Singh MD: When you step back and think about that, it's it's so irrational and I logical, of course we care about the root cause.
54:27
Sonia Singh MD: Of course we would like to address what the root issue is.
54:30
Sonia Singh MD: But I think where the disconnect happens is there's a lot of diseases, especially autoimmune diseases, where there is not one root cause that we have identified.
54:38
Sonia Singh MD: The fact that we have this antibody is great that we have something to point to, but.
54:42
Sonia Singh MD: I don't think we fully understand why some people develop this disease and some people don't.
54:47
Sonia Singh MD: And a lot of times there may be a variety of factors that are environmental epigenetic, lifestyle related.
54:53
Sonia Singh MD: And when I say environmental, I don't just mean toxins and pollutants, but just like viruses that you got or so many different things.
55:00
Sonia Singh MD: And so it's not that your doctor is uninterested in the root cause, it's just that your doctor is not going to make up a root cause when we don't actually have one to tell you.
55:13
Sonia Singh MD: And then same in terms of nutrition and exercise.
55:16
Sonia Singh MD: And I feel like I've taken some of my messaging around this from seeing you comment on these things when it we're in a lot of the same Facebook groups.
55:23
Sonia Singh MD: And sometimes people will say, I got diagnosed with this thing my doctor.
55:29
Sonia Singh MD: Gave me no guidance on diet and exercise.
55:31
Sonia Singh MD: I don't know what I'm supposed to be doing lifestyle wise.
55:34
Sonia Singh MD: Somebody helped me.
55:35
Sonia Singh MD: And I've noticed that whenever you comment, the first thing you say is nutrition and lifestyle is so important for every disease, or something along those lines where it's like we're not saying this thing doesn't matter.
55:48
Sonia Singh MD: And we all, as a medical community could do a lot better at discussing lifestyle and nutrition generally with our patients.
55:55
Sonia Singh MD: But when there is no specific evidence-based guidelines around nutrition for that particular thing, like there is not data to support removing something from your diet or taking a particular supplement, we should not be recommending that.
56:11
Sonia Singh MD: We cannot recommend that for every patient that comes with that.
56:13
Sonia Singh MD: And, that's often what people are getting when they go somewhere else and get that advice.
56:19
Sonia Singh MD: It's not that person.
56:20
Sonia Singh MD: Knows something that the doctor doesn't know or, has a different approach.
56:24
Sonia Singh MD: It is that they are comfortable with a much weaker level of evidence and using that to make recommendations and treatment decisions than somebody who is, practicing traditional evidence-based medicine is willing to do.
56:39
Rebecca Berens MD: Yeah, and I think the thing that I always hear is there's no harm in trying it, to act like there's no harm.
56:45
Rebecca Berens MD: If there's nothing I can do, why not just try it?
56:47
Rebecca Berens MD: Maybe it won't help, but maybe it will, there's no harm and.
56:50
Rebecca Berens MD: And I have observed many times that there is significant harm to trying, especially these very restrictive diets, because not only the harm of the mental brain space that you're taking up, focusing on reading ingredient labels and maybe buying more expensive food or expensive meal prep things or whatever.
57:08
Rebecca Berens MD: There's financial harm, there's time harm, there is disordered eating risk.
57:13
Rebecca Berens MD: Yeah.
57:13
Rebecca Berens MD: That is really true.
57:14
Rebecca Berens MD: And I think, I harp on this all the time, but it's because I see it so often where someone saw an alternative medicine practitioner for a condition that does not have any evidence-based guidelines for any lifestyle interventions that specifically help.
57:27
Rebecca Berens MD: And they were prescribed a very restrictive diet and it triggered their development of their eating disorder.
57:32
Rebecca Berens MD: I've seen it so many times.
57:33
Rebecca Berens MD: Yeah.
57:33
Rebecca Berens MD: And it is truly harmful.
57:35
Rebecca Berens MD: And it's it's also the harm of the shame for that person where it's like I did everything I could and I still.
57:41
Rebecca Berens MD: It wasn't enough.
57:42
Rebecca Berens MD: I didn't do enough.
57:43
Rebecca Berens MD: I didn't fix it, and I'm like, you couldn't fix it.
57:45
Rebecca Berens MD: But now you've been led to believe that you just didn't try hard enough.
57:49
Rebecca Berens MD: That is significant harm as well,
57:51
Sonia Singh MD: and that's very often the conclusion that they draw when it's not working, when the levels are not going down, their assumption is, I did not do it diligently enough.
57:59
Sonia Singh MD: Rather than questioning did this even make sense in the first place?
58:03
Sonia Singh MD: Yeah.
58:04
Rebecca Berens MD: And like it's truly harmful.
58:05
Rebecca Berens MD: And I think that's what makes, that's what infuriates me the most about it, is it is sold as this harm-free intervention that is expensive, ineffective, and harmful.
58:14
Rebecca Berens MD: And there's nothing about any of that I can ever recommend.
58:17
Rebecca Berens MD: If it is those three things.
58:19
Rebecca Berens MD: And none of us are making any money off of generic levothyroxine, we have no stake in the game.
58:24
Rebecca Berens MD: I promise you.
58:25
Rebecca Berens MD: I would love, if you're describing
58:26
Sonia Singh MD: that is'cause you need it.
58:28
Sonia Singh MD: I would love to know the root cause.
58:30
Sonia Singh MD: I would love to have a dietary intervention to tell people about, to prevent their progression to hypothyroidism.
58:35
Sonia Singh MD: That would be awesome.
58:36
Sonia Singh MD: I think there's this perception of but then the doctor loses the customer.
58:40
Sonia Singh MD: 'cause then, they would be treated.
58:41
Sonia Singh MD: But that is crazy.
58:43
Sonia Singh MD: I will tell you the people, I'm sure you feel the same.
58:45
Sonia Singh MD: I think all doctors feel, the people who come back over and over with the same complaints that you feel like you cannot fix are so challenging and sad for us.
58:53
Sonia Singh MD: And just we want to help people and fix them.
58:55
Sonia Singh MD: I would love for people to not need to see me as often, so anyway, now we're drifting into treatment though, and we should keep it, we're trying to keep this conversation to testing.
59:04
Sonia Singh MD: So I think we covered, the main tests that are often requested by people who are wanting a full thyroid panel.
59:11
Sonia Singh MD: I think we've reviewed, what are the evidence-based testing recommendations and we highlighted why people would be interested in more testing, why there's certain clinical scenarios in which that may make sense, why there's a certain art of medicine piece of this that, may justify doing some additional testing, assuming.
59:28
Sonia Singh MD: You have talked about what information comes from it, you have a qualified professional that's going to interpret it.
59:33
Sonia Singh MD: You have talked about the potential cost to the patient.
59:36
Sonia Singh MD: And so hopefully this has given people a little bit more of a broader understanding of, what thyroid testing is all about and why what your doctor offers you feels so different than what social media is telling you should get.
59:50
Rebecca Berens MD: Yeah.
59:51
Rebecca Berens MD: Alright, so I think we covered some of this already, but what can we learn from this as doctors and humans?
59:59
Sonia Singh MD: I think the biggest thing I take from this, which is often my take home is that.
1:00:03
Sonia Singh MD: Patients are just craving a better understanding of what is happening in their bodies.
1:00:08
Sonia Singh MD: I think that's why it's so attractive when people talk so much about thyroid physiology and explain all the nitty gritty details, and we just don't do that enough.
1:00:16
Sonia Singh MD: And I, I think part of that is a function of time and part of that maybe that sometimes we underestimate that patients really wanna know all these nitty gritty details and to us maybe it doesn't feel like it's that helpful or interesting, but it might be.
1:00:29
Sonia Singh MD: And I think we also don't do a good enough job of validating people's symptoms and their experience and kind of stopping at normal labs.
1:00:38
Sonia Singh MD: I think that's actually very common.
1:00:39
Sonia Singh MD: That happens commonly where I think somebody comes or feeling something, the doctor does the labs, they're like, it's fine.
1:00:45
Sonia Singh MD: And sometimes they drop it there and the patient has this perception that they're being told nothing is wrong with you.
1:00:51
Sonia Singh MD: And the reality is if you are not feeling well.
1:00:54
Sonia Singh MD: That is wrong with you.
1:00:56
Sonia Singh MD: Something is wrong with you.
1:00:57
Sonia Singh MD: And again, it may not be a disease that we can name, it may not be something that's gonna show up on a lab test, it may not be something with a diagnosis code associated with it, but that doesn't mean we should stop the conversation or, act like you need to just get over it or something.
1:01:11
Sonia Singh MD: And then in terms of how I am gonna try to talk to patients about this moving forward, I think I try to do this already.
1:01:17
Sonia Singh MD: I try to explain the physiology and just take that time, even if they haven't asked me to just explain what each of the tests I ordered means.
1:01:25
Sonia Singh MD: I try to do a good job of validating them and their experience and sometimes I'll be able to tell them like, I really thought you were gonna have hypothyroidism too.
1:01:32
Sonia Singh MD: I almost wished that you did because I know how to treat that.
1:01:35
Sonia Singh MD: And then I think lastly, just taking the time to just explain this, tendency to just ignore the lab science piece and the clinical piece, because I just think, like I said, that the physiology is so compelling to people and it just feels like people who are going in depth into that, really know their stuff.
1:01:54
Sonia Singh MD: But I think just pointing out that they're usually not touching at all upon how valid is this assay?
1:02:00
Sonia Singh MD: How accurate is this assay?
1:02:02
Sonia Singh MD: How does this translate in actual human beings and in clinical medicine?
1:02:06
Sonia Singh MD: I hope people start noticing that a little bit more.
1:02:09
Rebecca Berens MD: Yeah.
1:02:10
Rebecca Berens MD: I think for me, what I take away from this, from from both a doctor and a patient perspective is, I think the follow-up is so important.
1:02:17
Rebecca Berens MD: And I know you probably do this, I always do this.
1:02:19
Rebecca Berens MD: We always have a follow-up appointment to talk about labs.
1:02:22
Rebecca Berens MD: Yeah,
1:02:23
Sonia Singh MD: yeah.
1:02:23
Rebecca Berens MD: Regardless of if they are normal or not.
1:02:25
Rebecca Berens MD: Because I wanna make sure you understand everything.
1:02:28
Rebecca Berens MD: I tested what it means, and then also does this answer the question we were asking when we got these labs or not?
1:02:34
Rebecca Berens MD: Or are there still symptoms?
1:02:35
Rebecca Berens MD: And I think there's so many reasons in the healthcare system that those follow-up visits don't happen.
1:02:41
Rebecca Berens MD: But my push is always for patients.
1:02:43
Rebecca Berens MD: I think sometimes, and I had this experience when I was employed, you didn't wanna inconvenience the patient by making them come back just to get their lab results.
1:02:50
Sonia Singh MD: Yeah.
1:02:51
Sonia Singh MD: True.
1:02:51
Sonia Singh MD: And
1:02:51
Rebecca Berens MD: I've, I, and because I feel like people would, you would know what was going on with'em.
1:02:54
Rebecca Berens MD: Oh, they're so busy.
1:02:55
Rebecca Berens MD: Oh, there's, but you can't possibly remember every detail, every person's conversation when you're employed and have 150 things in your inbox in the morning.
1:03:02
Rebecca Berens MD: So you may not remember oh yeah, that we checked this though because they were feeling something.
1:03:06
Rebecca Berens MD: Yeah.
1:03:06
Rebecca Berens MD: Or some practices have a nurse just going through and all the normals they just send and all the abnormals they send to the doctor.
1:03:11
Rebecca Berens MD: Yeah.
1:03:11
Rebecca Berens MD: Yeah.
1:03:12
Rebecca Berens MD: You can easily miss things that way.
1:03:13
Rebecca Berens MD: And so I just would encourage patients if this is important to you.
1:03:17
Rebecca Berens MD: Book yourself the follow-up appointment, whether or not the doctor thinks that you need it or the clinic told you to that is what gives you the time to really go through those labs and understand what they are.
1:03:28
Rebecca Berens MD: And I'm sure that there's still lots of barriers to that and that's not, an easy answer for everyone.
1:03:32
Rebecca Berens MD: But I just encourage people like to, that isn't a self-advocacy step that you can take.
1:03:37
Rebecca Berens MD: To just go ahead and book yourself the followup appointment.
1:03:40
Rebecca Berens MD: Even if your labs were normal, make sure you feel like you understood everything.
1:03:44
Rebecca Berens MD: And then either that doctor can take you to the next step or they can't, and you wanna maybe look for someone else, but at least you feel like you got all of your questions answered.
1:03:53
Rebecca Berens MD: 'Cause it's just not gonna happen on the portal.
1:03:54
Rebecca Berens MD: It's just not yeah, like you just can't have
1:03:57
Sonia Singh MD: that kind of conversation on a portal.
1:03:59
Sonia Singh MD: When you have hundreds of patients and you're the lab, the thousands actually, and the lab queue is full of results and stuff without flags and it's all normal.
1:04:07
Sonia Singh MD: It's very tempting to just be like, Hey, everything looks great.
1:04:10
Sonia Singh MD: Send everything looks great, send.
1:04:12
Sonia Singh MD: And like you said, you may not, remember that, oh my God, that person was feeling awful.
1:04:16
Sonia Singh MD: So actually the message to say, Hey, I don't see any big red flags in your labs.
1:04:21
Sonia Singh MD: How are you feeling?
1:04:22
Sonia Singh MD: Let's talk about this again.
1:04:23
Sonia Singh MD: When can you come in and see me?
1:04:24
Sonia Singh MD: Yeah, I totally agree.
1:04:25
Sonia Singh MD: That's great advice.
1:04:27
Sonia Singh MD: In terms of, how to advocate for yourself a little bit on the topic of thyroid and hormones specifically, I find that sometimes when people are either just really anchored where they're just like, I really believe there's something with my thyroid, or they have already sought guidance somewhere else, and somebody has told them that there is something that they're wrong with their thyroid.
1:04:45
Sonia Singh MD: Sometimes I encounter these people in my meet and greets where they're like thinking about joining my practice.
1:04:49
Sonia Singh MD: I always tell them just go to an endocrinologist, go straight to an endocrinologist get a referral, ask per referral, and go to an endocrinologist.
1:04:55
Sonia Singh MD: 'Cause as we talked about, like TSH is adequate for 98% of cases.
1:05:00
Sonia Singh MD: But there's other diseases with the thyroid besides that.
1:05:02
Sonia Singh MD: And I have had cases where, somebody has had some rare issue that did require additional expertise that, was not picked up by me or was not picked up by their PCP.
1:05:11
Sonia Singh MD: So it can happen and if you're just really convinced or you're getting conflicting guidance from your PCP and then somebody in the alternative wellness world, endocrinologists are really going to be your actual experts on this topic.
1:05:23
Sonia Singh MD: And oftentimes I do see them go a little bit beyond what the PCP did, even if that was, not what the guideline would direct.
1:05:30
Sonia Singh MD: But I think that's worth doing to just put the question to bed rather than spinning your wheels or going deeper and deeper into a rabbit hole of information that is not evidence-based or helpful.
1:05:41
Sonia Singh MD: Yeah.
1:05:41
Sonia Singh MD: Yeah, I guess that's my other 2 cents there.
1:05:45
Sonia Singh MD: Yeah.
1:05:45
Sonia Singh MD: Actually, you know what, I wanna say one more thing, which is.
1:05:48
Sonia Singh MD: I said the last thing about the endocrinologist, because I wanna make clear that I feel like people are gonna listen to this episode and say I went to my PCP and they told me nothing was wrong.
1:05:57
Sonia Singh MD: And then maybe they did go to an endocrinologist and told them something was wrong, or maybe they went to an naturopath and they made some recommendations for lifestyle, and then they felt better, and then maybe their lives became normal.
1:06:07
Sonia Singh MD: I just wanna emphasize that I'm not saying those things cannot happen or they do not happen This is not meant to like, invalidate your experience or say that was wrong of you to do, or that did not work for you or deny that worked or, say that just didn't happen.
1:06:21
Sonia Singh MD: But as medical professionals, our job is to not base our decisions for people on an anecdote of something that worked well for somebody or something that worked well for my neighbor or my friend or my aunt.
1:06:33
Sonia Singh MD: It is really to use large, pools of evidence and the consensus of the world experts on these topics to make those decisions.
1:06:42
Sonia Singh MD: And so we're not gonna be right all the time.
1:06:45
Sonia Singh MD: And sometimes, you're going to find your answer somewhere else, that is what our job is to do, It's hard because I feel like sometimes I make these statements and then there are people who have benefited from seeing those types of practitioners or who have had a good outcome.
1:06:59
Sonia Singh MD: And, they're what about me?
1:07:00
Sonia Singh MD: You're just saying that all of this stuff doesn't make any sense and doesn't work, but it worked for me.
1:07:05
Sonia Singh MD: So anyway, that's a finishing point that I wanted to make.
1:07:08
Rebecca Berens MD: Yeah,
1:07:09
Sonia Singh MD: absolutely.
1:07:10
Sonia Singh MD: Okay.
1:07:10
Sonia Singh MD: So in terms of where people can go for more info, I will put a couple of links of well-vetted endocrinology, thyroid resources in the show notes.
1:07:19
Sonia Singh MD: We'll have our references also in the show notes and a few people on social media to follow for good evidence-based information.
1:07:25
Sonia Singh MD: That's the end of our show.
1:07:28
Sonia Singh MD: Hey guys.
1:07:28
Sonia Singh MD: Last but not least, we have a very important disclaimer.
1:07:32
Sonia Singh MD: This podcast is intended for educational and entertainment purposes only.
1:07:36
Sonia Singh MD: The content shared on this podcast, including but not limited to opinions, research discussions, case examples, and commentary, is not medical advice and should not be considered a substitute for professional medical evaluation, diagnosis, or treatment.
1:07:51
Sonia Singh MD: Listening to this podcast does not establish a physician patient relationship between you and the hosts.
1:07:56
Sonia Singh MD: We are doctors, but not your doctors.
1:07:59
Sonia Singh MD: Any medical topics discussed are presented for general informational purposes and may not apply to your individual circumstances.
1:08:06
Sonia Singh MD: Always seek the advice of your own qualified healthcare professional regarding any questions you have about your health.
1:08:11
Sonia Singh MD: Medical conditions or treatment options, never disregard or delay medical advice because of something you've heard on this podcast.
1:08:18
Sonia Singh MD: While the hosts are licensed physicians, the views and opinions expressed are our own and do not represent those of our employers, institutions, organizations, or professional societies with which we are affiliated, although we do our best to stay up to date.
1:08:32
Sonia Singh MD: Please note that this podcast includes discussion of emerging research, evolving medical concepts, and differing professional opinions.
1:08:39
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1:08:43
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1:08:58
Sonia Singh MD: Thanks again for joining us.