Posted by: notdeaddinosaur | November 22, 2014

Which One Did I Send?

Middle-aged lady, twenty pounds overweight.

Doing everything I can, doctor. Everything imaginable. Diet: I eat practically nothing. Exercise: all the time! Weight Watchers doesn’t work. Jenny Craig, South Beach, the Zone; I’ve tried it all. Nothing works. Have to lose weight. Have to lose weight.

Yadda yadda yadda.

Oh look: a few years back I diagnosed you as hypothyroid and gave you some Synthroid. Are you taking it?

Nah; I stopped that. I just didn’t want to take it.

Hm. Send some blood work. Low and behold: TSH is 7. That’s high, and it means her thyroid is underactive, which is probably a big part of why she’s having so much trouble with her weight.

She’s asked to be notified by email, so I sit myself down at my little keyboard and compose:

Labs are back; report attached. Cholesterol, sugar, blood count all fine. BUT: I don’t want to hear one more word from you complaining about not being able to lose weight IF YOU DON’T TAKE THE DAMN SYNTHROID. Your TSH is 7. That’s hypothyroidism. Until we get you titrated to a dose that gets your TSH below 2, nothing is going to change, including difficulty losing weight. So put your big-girl panties on and let me know where you want me to send a new prescription for synthroid. Then get back here in 6-8 weeks for another TSH. Dig?

But my finger hesitated over the SEND button. Could I really send that?

I hit SAVE DRAFT and started over:

Labs are back; report attached. Cholesterol, sugar, blood count all fine, but the TSH is still a little high. I really think you should try the synthroid again. It’s almost certainly the reason you’re having so much trouble with your weight. Why don’t you let me know what drugstore you use so I can send a new synthroid prescription. Then we can check another TSH in about 6-8 weeks. Okay?

I read both versions over again. Back and forth. Over and over.

Then I hit SEND.

Guess which one?



  1. You sent the second one. The first one was venting. But if the patient was in your office, you might ‘speak’ the first one. Xo


  2. It is less likely to work when it isn’t used:

  3. I know you really wanted to send the first one, but probably sent the polite one instead.

    Part of me also wonders: even though the thyroid is clearly an issue, would tracking her actual calories reveal that maybe she’s not following those diets as closely as she thinks?

  4. Oh, I do hope,it was the first one.

  5. I don’t know which one you sent, but if I was the patient I would want you to send the first one.

  6. Seeing as I have never once heard a doctor say “put your big girl panties on”, and I certainly have deserved it, I’m betting on #2.

  7. I have what I call a venting file labeled LETTERS WRITTEN BUT NEVER SENT and that is where the first version belongs. I long ago read a story where Abraham Lincoln told a young man who had written.a nasty letter and then asked how he should send it “Don’t, You never want to send such a letter.” Sage advice, and what’s good enough for old Abe, is good enough for me.

  8. […] Which One Did I Send? […]

  9. I had an OBGYN try to manufacture a subclinical hypothyroidism case out of me because their “well woman exam” tests showed that my TSH was slightly elevated, as it had been during another test years before (about 6 or 6.5, IIRC). I asked the cubicle fauna who phoned to breathlessly inform me of this what the normal upper limit was and she said snippily and grudgingly: “Four and a half, but people are USUALLY symptomatic over TWO!” (Their office wouldn’t manage the recommended drugging, so it was ideology rather than profit motivating the testing.)

    Now I have no symptoms of hypothyroidism; I had normal thyroid hormone levels, and I weigh under 105 pounds, have a fast pulse, and tend to be hyper. I figured that if I took artificial thyroid hormone, either I would then have abnormally high levels and be a basket case, or my natural production of the stuff would drop off, and after years of that, might or might not come back if I ever couldn’t get the drug or wanted off it. In other words, would I not be paying to be made either hyperthyroid or hypothyroid? I got on PubMed and found authoritative reviews that said that up to 20% of females over 60 (I’m not that old…) had TSH levels above the reference range; there is certainly no justification for further slashing that range by more than half [to 2]; there was no evidence that medicating healthy women with normal TH levels and TSH levels below *10* [!] had any benefits; and that it was not known what long-term harms might accrue from doing so.

    Naturally, that was the last time I say that OBGYN. Now, since your patient has weight issues maybe she is idiosyncratically symptomatic and should give Synthroid another try. Or maybe she tried it, started having side effects of excess hormonal medication, and quit, while recognizing that there’s no point in explaining this to a doctor who would even desire to respond to a patient who pushes back against her treatment goals with patronizing and belittling rhetoric. I can assure you that if a doctor reacted to my refusal, based on scientific literature, to instantly accept lifelong medication with snot about “big girl panties,” I’d be on Yelp the next day.

  10. Sorry, dear. Dino’s patient has a TSH of 7 and that is hypothyroid no matter what you read on the internet. It’s up to the patient whether or not to take the medicine. However, if they choose not to they shouldn’t whine about the symptoms said medication was to treat. And you’d be getting a discharge letter from me to mention on Yelp too.

  11. OK….what the hell did you send….I am a psychotherapist and do speak to my patients ….that I have good rapport with…like that and it works Being only a peon in the clinic and not the MD I would most likely,if in writing,have sent number 2.

  12. mamadoc – If you read carefully, what I “read on the internet” is abstracts and full texts where available, located by searching NIH’s official PubMed website, of articles published in paper medical journals. It’s fashionable among doctors to fulminate against patients who read, but if what they’re reading is clinical trials, meta-analyses, or reviews that don’t support your beliefs, firing them for wanting to consider scientific evidence would make you look really bad.

    If you bothered to read the same literature, you would know that while some people with moderately elevated TSH do have symptoms that are reduced by taking TH, others have no symptoms, or coincidental potential “symptoms” that have nothing to do with their TSH level, and taking TH can only leave them feeling the same or worse. Firing patients for refusing even a single one of the interventions you propose to dish out over a lifetime would also make you look really bad. It says there will be no shared decision-making or consideration of patients’ values here – you do as I command, or else. You tried the stuff once and had a bad experience? Tough rocks – keep swallowing.

    At least one of my family members has been fired by a doctor who had previously committed life-altering, perhaps ultimately to be fatal malpractice on him, so I’d take such a discharge letter as a dodged bullet. Dear.

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