Switched Keys

Medical care is one of those services that is difficult to judge. You don't know if you have been provided the best, or even adequate care unless you know something about medicine or consult with someone else that knows. It's unfortunate that the only reviews most people can provide is whether or not the physician is friendly.

However, if you've spent time researching the field you can be conversant with the doctor, and better judge the quality of care received. The challenge is to adequately research the specific issues.

Clinic sites are okay for basic research, But if you learn the terminology and search articles published in medical journals you get a better idea how treatment measures up to industry practices.

In particular, I've spent a considerable about of time researching and attempting to find some information that would help my wife's case with symptoms of hypothyroidism.

Knowing a little about that specific area of concern, I'm disappointed with the medical care at UT Health East Texas recently provided, at two levels.

Family Practice

A few years ago my wife was complaining about being cold all the time, and exhibited other symptoms of hypothyroidism, such as constipation, and slow wound healing.

When I brought that to the attention of her primary care physician (PCP) she ordered a thyroid test (TSH) and when the results were supposedly normal she had no other concern about that.

When I subsequently brought her symptoms to the attention of her PCP, the doctor simply said she tested and her thyroid was normal and voiced no other recommendations to address the symptoms.

I've since researched a lot and discovered that you can have hypothyroidism with normal TSH, and this year I talked the PCP into getting a referral to an endocrinologist. At first she said she couldn't with normal TSH, but then I convinced her to attempt a referral based on symptoms. I figured a specialist would be more likely to consider more recent findings.

The Endocrinologist 

After the endocrinologist renewed her records the endocrinologist also insisted that her thyroid is normal, but she did order another test, this time FT4 (free Thyroxine) and reiterated that her thyroid is normal, and offered no other advice concerning her symptoms.

A past TSH was high normal, and the current FT4 was low normal. I would've expected a thyroid specialist to order a complete thyroid panel including T3 and antibodies.

This particular endocrinologist, however specializes in diabetes not hypothyroidism.

Her UT Health bio mentions her continuing study of diabetes technology and I don't doubt her expertise in diabetes, but it doesn't translate into a expert knowledge of thyroid disease. 

Also, unlike the other physicians in the department, based on UT Health biographies, this endocrinologist was neither board certified in endocrinology, or affiliated with a professional organization like AACE, Endocrine Society, or the American Thyroid Association.

Research ignored 

At the appointment I had prepared a couple of sheets of thyroid research i had done. I'm not talking about individual blogs, and patient opinions, or even clinic websites (which may not be updated).

The research I'm taking about was mostly research articles published in medical journals specific to that specialty. Additionally, it was not usually research of an individual doctor, but often teams of researchers.

When I presented it to the endocrinologist she simply ignored it and repeatedly insisted that her thyroid is normal and has always been normal.

Research 

As previously mentioned, what I've found first off is that you can have hypothyroidism with normal TSH.

Even more significant was the research that recommended updated TSH test ranges, with upper limits ranging from 2.0 to 3.0 mIU/L.

I've prepared similar research and presented it to other doctors only to be routinely ignored. In the hospitals, one of the hospitalists viewed hypothyroidism as a chronic issue while the hospital is only there for acute issues. 

ATP, I anticipate presenting the details in a later post.

Symptoms ignored 

While there is some debate on what is normal TSH reference range, the upper reference range combined with the symptoms should warrant more investigation. Yet, with the PCP and the endocrinologist, there was little interest in addressing the symptoms. 

There's a number of symptoms related to hypothyroidism, directly or indirectly. Those symptoms could also be due in part to other diseases, but with her specific combination of symptoms, the Wed MD symptom checker found them to be a strong match for hypothyroidism.

I attempted to share those symptoms to the endocrinologist. 

BMI dispute 

The Endocrinologist made no comment about her cold intolerance, but when I mentioned recent bloating and weight gain she quickly calculated a number for BMI (body mass index) and said that was normal. One of the problems with that is that she did not consider that my wife is a paraplegic amputee. 

It should be obvious that traditional BMI would not be an accurate guide for an amputee. Some guidelines recommend reducing the weight for calculation based on the level of amputation.

It's also been suggested that BMI is not a useful guide for paraplegia, and recommend calculating ideal weight by adjusting for the level of paraplegia.

Finally, BMI is only a guide and you have to consider body build (frame) and composition (fat, lean muscle, etc) such as percentage and location of fat. 

So I pointed out, based on research, that the ideal weight should take paraplegia and amputation into consideration. For someone of normal build (frame), ideal weight for paraplegia should be 10-15 percent less. After that you have to account for the aka amputation, in this case about 10 %. 

Although that is noteworthy, the biggest problem was not her weight, but her weight GAIN, and location around the waist. That's what makes her weight an issue when diagnosing hypothyroidism.

I mentioned a couple other symptoms with no response.

The Referral

Finally, I question the wisdom of providing the referral. There are physicians in the department that do treat thyroid problems, but she was referred to this endocrinologist with seemingly no more expertise in thyroid problems than a family practice doctor. Maybe she was the only one taking new patients.

Although there are family doctors that do successfully treat thyroid disease, particularly hypothyroidism.

Summary 

My wife's symptoms may indeed be the result of one or more other medical issues, but adequate testing was not done to rule out hypothyroidism.  

Caveat 

This is not meant to be a criticism of UT Health East Texas as a whole. I have found the services of the Wound Healing Center at UT Health East Texas to be excellent on multiple occasions. The doctor had a plan and carried it through with good results. The center has three doctors and a nurse practitioner, each of them with at least one board certification in wound case.

That is in contrast with more recent experience of home visits with Wound Management Specialists. With them we had a nurse practitioner, graduated less than two years ago, with no board certification. She knew about treatments but didn't seem to have a good plan of care. Maybe I can write about that and White Rock Medical Center in a later post. 

Concerning UT Health East Texas, as a university hospital I thought the physicians there (often also professors of medicine) would be more in tune to recent research and be more thorough in their diagnoses. In some schools I know the professors are expected to also publish research. That type of inquisitive mind is what is needed in medicine.