The Antisocial Doctors Podcast
Join Dr. Rebecca Berens & Dr. Sonia Singh as they unpack viral health trends with curiosity, nuance, and compassion. No snark, no shame —just thoughtful conversations about what’s true, what’s hype, why we're drawn to it and how to find calm and clarity in the chaos of social media and online health advice.
The Antisocial Doctors Podcast
Episode 4: Do I Need A Full Thyroid Panel?
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In this episode of the Antisocial Doctors Podcast, hosts Dr. Sonia Singh and Dr. Rebecca Berens delve into the intricacies of thyroid testing, discussing the basic and full thyroid panels commonly debated on social media. They explain the physiology of thyroid function, the roles of TSH, T3, T4, and antibodies, and the evidence-backed guidelines for thyroid testing. Through patient stories and expert commentary, they debunk misinformation, highlight the limitations of excess testing, and emphasize the importance of clear communication and follow-up in medical practice. This episode aims to clarify common misconceptions and advocate for a more nuanced and evidence-based approach to thyroid health.
00:00 Welcome to the Antisocial Doctors Podcast
01:13 Introduction to Today's Topic: Thyroid Testing
03:27 Patient Story: A Journey with Thyroid Issues
06:20 Understanding the Full Thyroid Panel
16:54 The Complexity of Thyroid Testing
32:34 The Role of TSH in Thyroid Diagnosis
33:57 Thyroid Screening Basics
35:27 Understanding T3 Testing
36:45 Conversion Issues and Malnutrition
41:34 Reverse T3: A Misunderstood Test
45:03 Anti-TPO Antibodies and Hashimoto's
47:34 Patient Experiences and Misconceptions
01:03:00 The Role of Endocrinologists
01:05:43 Conclusion and Resources
📖 Read the full episode summary, sources, and resources on our Substack:
👉www.theantisocialdoctors.com
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
Rebecca Berens MD:and me, Rebecca Barons, a board certified family medicine physician with a special interest in disordered eating.
Sonia Singh MD:We're also a millennial women anxious moms and curious humans navigating social media. We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
Rebecca Berens MD:This podcast is meant to be the antidote to your doom. Scrolling, a, solve for the anxiety, stress, guilt, shame, and confusion. That comes from social media's messaging around health. In each episode, we discuss a health related talk trending on social media with curiosity, nuance, evidence, humility, and compassion.
Sonia Singh MD:This is not your average debunking podcast. We wanna explore not just what is trending on social media, but why? Why are so many people drawn to this? What is the nugget of truth here? What are the facts? What can we learn from this as patients and doctors? No shame. No blame, no snark.
Rebecca Berens MD:We're so glad you're here.
Sonia Singh MD:Okay, so let's get started. Hi, Rebecca. Hi Sonia. How are you? I'm good. How's your week going? It's going okay. So I'm gonna be open and honest here. I am like really nervous to record this episode because the topic today is thyroid testing. And this is a topic that I just think there's a lot of people that are very passionate about it. 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. And so I think there's just a lot of controversy and disagreement on this topic. 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. Decide that we're gaslighting them or we're narrow-minded or that we just dunno the physiology well, or, 800 other things. So anyway, I'm nervous about that,
Rebecca Berens MD:yeah. 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.
Sonia Singh MD:Yeah.
Rebecca Berens MD:And it is important and it is relevant. And we are testing another thing to roll that out. And normal results of that testing doesn't mean that what you're experiencing is not real. Yeah. Or that it also does. And it also doesn't mean that there's not. Something going on that is, potentially relevant to your thyroid. It just is, the medical guidelines in this case are about thyroid treatment. 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. But affect symptoms related to thyroid. So anyway, we'll get into the topic I think. Yes. 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. That's happens a lot in medicine.
Sonia Singh MD:No, and you're right. 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. And so that's always nice to. See those threads, those common threads. Okay. So as always, we're gonna start the episode with a patient story. I had a patient that joined my practice a few years ago. She's still with me. 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. So she had gone in not feeling right, having some symptoms. They said, Hey, look your TSH test is abnormal, but your free T four test is normal. So at this point, the recommendation was we're gonna monitor this and recheck it. We can talk about maybe medication. So she heard this diagnosis and immediately thought I wanna be proactive. I do not wanna end up on thyroid medication. I want to do something preventive. I'm willing to change my lifestyle. I'm willing to change my diet. I need more guidance on how I can do this. And she didn't feel like her doctor gave her any of that. So she ended up seeking care with an alternative practitioner who did a full thyroid panel, which is the topic of today's episode. And that practitioner diagnosed her with Hashimoto's thyroiditis. 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. Thank God this person has gone an extra step. And done more testing and determined what the cause of my thyroid dysfunction is. And this person was offering her all kinds of treatment recommendations. So they basically told her, look, your antibody levels are so high, you are super inflamed. You need to work on an anti-inflammatory diet. They had her cut out gluten, they had her cut out dairy, she was avoiding cruciferous vegetables. And they gave her this huge variety of supplements like iodine, selenium, a bunch of other thyroid support things. 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. And I think, in comparison to her experience at her PCPs office where she felt like someone just said, yeah, these are the numbers. You could take a medication or not take a medicine, you can take it, in a few months. You may end up on medicine eventually. There's nothing you can do to prevent it. I think compared to that experience, this was a really positive experience. So I think stories like hers, honestly I hear them not infrequently. 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. 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. 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.
Rebecca Berens MD:Oh, absolutely. So yeah, I'm excited to hear all that we're gonna talk about in this episode. But let's start with, know what is the claim that's made around. The full ARD panel compared to the traditional testing that we are doing in a regular PCPs office. 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?
Sonia Singh MD:Yep. 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. 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. 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. Now, what is a full thyroid panel? 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. 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. 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. The question is why has this become viral? I have a long list of ideas. 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. Hot topic for so many years.
Rebecca Berens MD:Yeah. I think the thyroid conditions can affect so many symptoms.
Sonia Singh MD:Yeah.
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. Yeah. So many things can cause fatigue. 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. 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. And they're like, oh your thyroid's normal and you don't have any other explanation. And then someone else that you go to, like in your example is actually they just didn't do the right test. And look at all these things that are wrong with you, and if we fix it, we can fix all your problems. It feels very exciting to have an answer and there's something you can do. And so I think people are really drawn to that. 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.
Sonia Singh MD:Yeah, I totally agree. So what I had written down was just so many of the symptoms of thyroid disease can be subtle variable, not that specific. It's almost like reading a horoscope, where you read something and you're like, that sounds like that could be me. 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. That seems like it checks all the boxes of what I'm experiencing. That's gotta be it. And I will tell you, even as a clinician, sometimes I have felt like that. I've definitely seen patients where I'm just like, this person definitely has hypothyroid. They've got, I, their TSH is gonna be 20. I just know it. And it is a little crushing when you get the results and you're like, God darn, that's not what it is. 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. 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. No, it's not actually that. 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. Those symptoms, which can be caused by a variety of other issues, can just look. 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. 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. They are real, they're not imagined, they're real. 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. 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. And then tests come back normal. 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. 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? 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. 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. And then with the thyroid, it's so easy, like extremely easy to go to another place. And if you are convinced that you have a thyroid issue, if you want a thyroid diagnosis, you can almost find it. Anywhere, like you can find somebody who will check enough things that something will be abnormal and they will say, yes, you do. 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.
Rebecca Berens MD:Yeah. 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. That's built into the system, right? 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. And, doesn't even cover asking any questions about anything you might have experienced. But that's a whole other, that's a whole other podcast. But you go in and it's okay, do your labs. If something's wrong, come back, otherwise I don't wanna see you. Which really is not the way that primary care is designed to work, or at least that we're trained. I think especially with complicated chronic, multifaceted conditions and symptoms the answer is in the follow-up over time. The answer is never gonna happen from one lab test. 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. You're like, here's a pill, everything's fixed, and everything's better. That happens and it's so satisfying when it happens. Yes. Yay, we fixed it with this easy, cheap pill. Yes. But actually most of the time. It's complex. There's multiple things going on, and the answers are gonna come gradually over time in the follow-up. But, that's difficult and expensive for patients to take time off work to go to much multiple follow-up appointments. The appointments are not even that long to be having these kinds of conversations at those visits. 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. And then it's just like feeding people directly into the arms, open arms of the alternative practitioners who wanna give them answers. 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. It's gradual over time. Yeah. And yeah, I think that's like a big function of the weight, just the structure of the healthcare system that feeds into that.
Sonia Singh MD:So that touches on a really important point. I totally agree. 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. 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. If you don't have a disease, you just shouldn't be here. Or what diagnosis code am I billing this for? What is the reason for this visit? But so often in my practice now I'm like, okay, this person is stressed. They don't have anxiety or depression yet. They don't have adjustment disorder. 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. And that's, it feels like, where, when are you supposed to talk about those things? 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? And I think because it's just such a hassle to get into the doctor anyway, and you get such limited time. We really don't welcome that. Those types of conversations, we make it so hard for people to do that kind of proactive, preventive stuff with us. 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. No, nothing is wrong with your thyroid and somebody else does this fuller panel and find some little abnormalities here and there. 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. 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. Yeah, I think all of that, is part of what drives people to seek. Full thyroid panel and to look outside of traditional medicine for this.
Rebecca Berens MD:Yeah. So let's talk now about what are the facts? What is, what are the tests that, the typical thyroid panel or the standard thyroid panel, like what are we testing? What is that telling us about the thyroid? And then what are these other tests doing?
Sonia Singh MD:Yeah. 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. 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. Everything on it. I'm like, you don't know this. The menu of LabCorp is like thousands and thousands. You cannot possibly check everything. Technically does doing more labs give you more information? Yeah, it does give you more information, but the question is just is that information valuable, helpful, actionable? What are we gonna do with that? And does it actually help you at all? A lot of these tests, even in this full thyroid panel, are recommended, or indicated or helpful in certain clinical situations. So under the right circumstances, it absolutely makes sense to check an antibody. 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. The question is this needed for everybody, for screening? For anybody who's just concerned about, low thyroid function. It is also true that the thyroid is just not a simple organ. 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. There may be some information to be gleaned from that. 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. It's not the end of the road in terms of understanding one organ's function or an entire person's health or anything. I think. 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. 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. 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. In medicine we're constantly taught don't order a test. That is not gonna change your management. You always wanna ask yourself, okay, why am I checking this? Does it make sense to check it? And how is it gonna change my plan? 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. Then in, in our medical training, the guidance is you probably should not do that test. 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. 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. 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. 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. But maybe in select clinical scenarios, I might choose to do a test or two that I know is not gonna change my management. 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? And I think about that a lot more in the context of menopause, but I think it's applicable here too. I don't know what your thoughts are on that.
Rebecca Berens MD:Yeah, no, I totally agree with that. I think it's so interesting'cause some part of these guidelines are based on cost, right? 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. Cost of a test is part of it, right? Yeah. 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? Like they truly may not have the option to have a certain test done if it has not been deemed appropriate by. The guidelines for that. And it's not only based on the medical necessity, it's also based on cost benefit. Yes. 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. 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. But it's but I'll pay. Yeah. And that's one of the interesting things about being private now. 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. And it's talking them down Hey, too much information is not helpful. 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. And then also just the time expense and the anxiety brain space expense, right? We have to, there has to be a limit somewhere.
Sonia Singh MD:But there
Rebecca Berens MD:is probably a place for, like you're saying, doing a little bit more testing to help people better understand. 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. I see this a lot with insulin resistance. Like I do routinely check insulin levels now on my patients which I did never did in employee practice before. 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. But it, but I think it is very motivating to a person to understand My blood sugar is normal. My cholesterol's normal now, but I know I have this family history of diabetes and hey, I do have some insulin resistance. 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. Yeah. But I do think that, and I would argue that it does change management and in thyroid it's not quite the same.
Sonia Singh MD:Yeah. But,
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. Yeah. You told me. Which, we'll get into this, but it is sometimes very difficult to convince people that they're undereating, but. Their T three conversion will show you. 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.
Sonia Singh MD:Yeah, that's, no, that's a really good point. And I think you're absolutely right. 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. It's not changing your advice, it's not prompting you to prescribe them anything or do further testing. So what is the point? 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. So yeah, I think that's a great point. So next we're gonna cover a little bit about what are the facts about thyroid testing? And we're gonna, I'm gonna try to discuss it with some context and some nuances. And I wanna preface this by saying I am not an endocrinologist. You are not an endocrinologist. There are people who are much more expert on all of this than I am. And honestly, this episode is a little bit of a high view broad overview of this topic. And you could go way deeper on each of these things. But I'm gonna try to give a broad strokes overview here. The thyroid is an endocrine gland. It sits at the base of your neck. It produces thyroid hormone, which controls and influences all these different processes in your body. TSH, which is thyroid stimulating hormone is actually produced by the pituitary glands. It's not even, produced by the thyroid. The pituitary gland is in your brain and it basically tells the thyroid to make thyroid hormone. So the thyroid is mostly making T four. It's also making some T three and T three is really the thyroid hormone. And then T four gets converted to T three according to your body's needs. And importantly, that is happening mostly at the tissue level. 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. We'll talk more about whether that's meaningful and worth checking, and then there's gonna be total and free assays for both. T three and T four and total just means you're counting the amount that's bound to something. So your thyroid can be underactive, overactive, or can have some other more rarer dysfunctions. 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. So in hypothyroidism, your thyroid is a little underactive and sluggish. 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. And so in hypothyroidism, the TSH is actually going to be high and the free Z four will be low. 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. So it's gonna be low. And then your T three and T four may be high. And then there's subclinical versions of both hypo and hyperthyroidism. So in the subclinical version, the TSH has become abnormal, but the free T four is still normal. 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. 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. And honestly, they do a much better job of that than we do in medicine. I think often because of time pressure or various other reasons. 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. Like it's a little counterintuitive that high TSH is hypo, associated with hypothyroid or lower thyroid function. 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. They told me I was high. They told me I was low. I can't remember. They've clearly had such little. Good communication about what these tests mean and what they're checking. 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. 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. T three is your active thyroid hormone. 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? And so I think when you someone explains the physiology in depth to you, it's. 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? And then I think they're very quick in that world to say you can check them. There's all these other things, like why would you not check these? And I think the point I wanna remind people of is that. 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. And it's really just the starting point and then, to decide. What testing makes sense and to interpret those tests and decide how they influence management. You can't just look at physiology or just know physiology really well. 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. 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. And those second two parts are almost never part of the equation. 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. And then quickly goes to and therefore these are the tests that you need. And, how do we make those tests look normal? And that's the goal. And I wanna put it out there because I think. I see this also, I studied nutrition and so I've seen a lot of nutrition related misinformation out there. 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. 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. 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. 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? The outcome is no different. They don't really have any benefit from it. 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. And that is extremely common in the world of nutrition and supplements. And so anyway, I wanted to drive that point home.'cause I think it comes back over and over again.
Rebecca Berens MD:Yeah. 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. There's something you're not telling me. Yes. And they're like, let me lay it out for you. But even the alternative practitioner, like laying it out for them, like probably is missing a lot of these details. Yeah. And it is so hard. We went to school for a very long time to learn all of this stuff, right? It is very hard to summarize all of that in a quick blog post or a two minute reel. 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. Yeah. 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. And but I think it just, that's what opens the door for people to. To get the information from someone else who is willing to give it to them.
Sonia Singh MD:Yeah. 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. But the reality is that type of mechanistic thinking is often really an oversimplification of clinical medicine generally. 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. Okay. So I wanted to talk a little bit more about what that lab research and clinical research tells us about thyroid testing. So we'll start with ts H and we'll go through each of them. TSH is the most sensitive and specific marker for detecting primary hypothyroidism. So if you are concerned about low thyroid function, that is what you are going to the doctor for. TSH is going to be your most valuable test. 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. And specific means that if this test is abnormal. Typically it is going to be because of thi low thyroid function as opposed to some other cause that is, causing that abnormality. In medical school and biostats and epidemiology, we learn that, sensitivity of a test is really good for ruling something out. 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. And so the sensitivity of TSH for detecting primary hypothyroidism is 98%. So you would miss like 2% of cases if you were just relying on the TSH. But as far as lab testing goes, and also people forget that lab testing is fallible in itself and is not always right. But as far as lab testing goes in medicine that is pretty darn good. So it is super sensitive, really good for ruling out thyroid dysfunction and that is why so many doctors. Start with the TSH as the basic screening test for thyroid disease. 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. 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. Luckily we have these tests that are TSH reflex to free T four, which means they're gonna run a TSH on your labs. 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.'cause I always felt like that was the worst part of doing the two step process that is recommended. And now we have a way around that. 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. And they want their thyroid evaluated, and the doctor has done a TSH and a free T four. 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. They're following the guidelines of the two biggest societies that, are composed of the world's experts on these topics. So they're following evidence-based guidelines. 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. Okay, so moving on to T three. The first question to ask is this lab helpful to check and can we check it accurately? And, or is this result meaningful? 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. One is just. A function of the assay itself. It's just not as good of a test and it's not as accurate as our T four testing. And so that's part of the reason we're not checking it as often as, we check the T four. Secondly, a lot of the conversion of the T four to T three is happening at the tissue level. 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. 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? It's not, it doesn't end up being that valuable. Now that's not the case for people who are already on treatment. So there's a lot of other clinical scenarios in which you've. 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. Then there's the question of conversion. 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. So the amount of active thyroid hormone that your tissues are actually, receiving is low. And you, that's why you have all the symptoms of hypothyroidism. 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. Enzyme deficiencies where you actually cannot do that conversion. But those are extremely rare. So I actually learned this in medical school as oh, this is such a rare thing to see. That's why we don't check it. And you actually taught me of a clinical scenario in which it may actually be helpful to check. So I'm gonna let you share it.
Rebecca Berens MD:Yeah. 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. Yep. One of the ways that our body conserves energy when we are chronically, not receiving adequate calories, is by slowing down. Energy consumption throughout the body. And one of the most efficient ways to do that is to slow down thyroid conversion. Because the thyroid ramps up and down lots of different body systems. Yeah. 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. Yeah. And so this is very something that I very often see. And it is amazing how someone who is not, maybe receptive or believing that what they're eating is not enough. And which is common, people who have eating disorders often are not. Aware, and they're in a lot of denial. There's a lot of stigma around it. It, there's a lot of complicated reasons why someone might not believe what you're telling them when you're worried about malnutrition. But this is a very, again, just to drive from the point of once they see the data, it's hard to ignore. This is not working. Like your body's actually not producing a hormone that it needs because it is trying to conserve energy. So this is something that, that we see. But again, this does not diagnose a thyroid problem, right? This diagnosis, a chronic malnutrition or other sort of severe illness problem. And I think that's where the misunderstanding is. You still don't have a thyroid problem just because the thyroid test is abnormal, right? Your thyroid's fine. It's a non thyroidal illness that's causing this. And that's where people get so upset about oh, they didn't really check my thyroid. I'm like, they did. Your thyroid does work.
Sonia Singh MD:Yeah.
Rebecca Berens MD:There other things going on that are causing you to feel that way? But your thyroid itself is actually working, and so thyroid hormone is not the way to treat that problem. I could give you tons of thyroid hormone if you're not gonna convert it, what's the point? But the point is, treat the non thyroidal illness. 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. And so it's not a thyroid problem just because a thyroid test is abnormal. But it is useful information to understand your symptoms, but it's still not a thyroid problem.
Sonia Singh MD:I feel like I have seen people with, just. 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. Oh, yeah, there's those, I forgot. They can't be diagnosed with thyroid illness and especially, I guess that's true. 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. They can put you on something. Hopefully they're also not
Rebecca Berens MD:able to write a prescription. But who knows? 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. Yeah. 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. Or nothing happens and it doesn't change anything'cause it just doesn't convert it. But either case is. Not helpful. You haven't treated the problem right.
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. I don't are telling you, already. 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. So anyway, I think that's a really interesting example and you taught me about that. All so Let's talk about reverse C3. So I feel like reverse T three sounds like very fancy and people are always like, oh, but what about my reverse T three? It's really just like a bust of a test, it's not very helpful. So the American Thyroid Association. 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. It doesn't improve diagnostic accuracy. In addition to the other tests that we've already talked about, it's not recommended by really any clinical guidelines. Mainly because when it is altered or abnormal, it's typically from non thyroidal illness. So it's really not evaluating the thyroid very meaningfully. And so I wanted to take a moment to talk about this and we're touching on it by talking about malnutrition. 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. It's due to some other illness that's causing those aberrations. And the classic things that, we're taught to think about is severe illness, starvation, malnutrition, sepsis, trauma, major surgery. 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. But I have a highlight saved on there that's called thyroid. 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. And if you look at a lot of the studies she cited in that they're actually referring to people with thyroid six syndrome. And a lot of them are very sick. Like the studies are in ICU patients or in. 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. 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
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? 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. 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. It's not quite the same. Yes,
Sonia Singh MD:yes. Yeah. 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. And I talked about why they were not really proving the point that she was trying to make. Next I wanted to talk about anti TPO antibodies. 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. And the most common antibody that's detected in Hashimoto's patients is the anti TPO antibody. And the second most common are the thyroglobulin antibodies, but those are a lot less common. 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. And those are in patients with subclinical hypothyroidism. 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. And the risk is twice as high if somebody has antibodies present versus if they don't. So that would just prompt you to maybe, monitor their thyroid a little bit more frequently. And by frequently, the guidelines are like six to 12 months. So it's really not this is dramatically changing how often you're getting labs.'cause a lot of people are getting these labs once a year anyway. And the other scenario in which you may check an antibody level is when somebody has a goiter. In that case it can help you determine if someone has an autoimmune thyroiditis or if they may have a multinodular go. In that case, you're probably also doing some imaging. In those specific contexts it is maybe valuable. It can be checked to determine the cause of someone's primary hypothyroidism. But they actually advise against checking it as part of a general evaluation for suspected hypothyroidism. 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. If we're referring to that entire population is having Hashimoto's, that's a lot of people. And the rate of progression of somebody with antibodies to overt hypothyroidism, so like something that must be treated is two to 4%. 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. They have this, like my patient, I think had this feeling of oh my God, I've gotta get to work.'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. And it's important to note that doesn't actually happen. It's certainly not like a you are going to have this problem, imminently. Yeah.
Rebecca Berens MD:And this is actually something that I personally experienced. Where, so my mom has hypothyroidism and has Hashimoto's. 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. And so I was like I haven't had a physical in a while. Let me go just make sure everything's fine. My mom had at that point recently been diagnosed with hypothyroidism. And so I was like, oh, maybe I have it too. Maybe that's why I can't get pregnant. So I went to my PCP at the time and they. Talk to me. And this is the struggle of being a doctor patient. I told them the reason that I was concerned and I think they thought I wanted them to check if I had Hashimoto's. I really just wanted to check my thyroid. But anyway, they ordered the antibodies along with the TSH and free T four. 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. It must be my thyroid's finally gone. Yeah. 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. That is immediately where my brain goes. Yeah. But I can only see that it's happened to me. Even with all of the knowledge that I have, any patient would. Logically come to that conclusion. 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. 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. 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.
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. Why would that not make sense? Why would I not wanna do that? 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. But that is completely contrary to what is recommended by our, expert guidelines. 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. Hypothyroidism. So not only are they saying this does not guide your treatment. They're like, it doesn't tell you anything about whether this person is gonna be symptomatic or whether they're gonna progress. 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. 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. I don't know why you have this. You may progress to hypothyroidism, you may not. When you do, you can take a medicine and that is all you're getting. It's so unsatisfying. You're like, it's great sounds, it's totally unsatisfying, it's totally unsatisfying. Meanwhile, you go to somebody else who's these are these levels. We can track them. 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. 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. And she had gone and done, I guess I'll give you the update on her. She had gone and done all of the things, she was trying so hard. She has little kids with their own dietary stuff. So she was just like, it's been so hard trying to follow this. I'm trying to do the supplements I'm trying to do. 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. They didn't, there was no clear trend. They were just bouncing all over the place. 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. And I remember just thinking what? 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. And like I said, I don't think she felt like she was torturing herself. She felt like it was actually very helpful and validating and empowering when she started on this journey of trying to fix her thyroid. But ultimately, all of the things she was doing were not very evidence-based and they did not really seem to make a difference. And so ultimately She went on the medicine and now her levels are normal. 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. They just are like, take the medicine or don't take the medicine. Those are your only options. And I think this idea that. 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. 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. Of course we would like to address what the root issue is. 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. The fact that we have this antibody is great that we have something to point to, but. I don't think we fully understand why some people develop this disease and some people don't. And a lot of times there may be a variety of factors that are environmental epigenetic, lifestyle related. 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. 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. And then same in terms of nutrition and exercise. 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. And sometimes people will say, I got diagnosed with this thing my doctor. Gave me no guidance on diet and exercise. I don't know what I'm supposed to be doing lifestyle wise. Somebody helped me. 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. And we all, as a medical community could do a lot better at discussing lifestyle and nutrition generally with our patients. 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. We cannot recommend that for every patient that comes with that. And, that's often what people are getting when they go somewhere else and get that advice. It's not that person. Knows something that the doctor doesn't know or, has a different approach. 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.
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. If there's nothing I can do, why not just try it? Maybe it won't help, but maybe it will, there's no harm and. 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. There's financial harm, there's time harm, there is disordered eating risk. Yeah. That is really true. 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. And they were prescribed a very restrictive diet and it triggered their development of their eating disorder. I've seen it so many times. Yeah. And it is truly harmful. 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. It wasn't enough. I didn't do enough. I didn't fix it, and I'm like, you couldn't fix it. But now you've been led to believe that you just didn't try hard enough. That is significant harm as well,
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. Rather than questioning did this even make sense in the first place? Yeah.
Rebecca Berens MD:And like it's truly harmful. 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. And there's nothing about any of that I can ever recommend. If it is those three things. And none of us are making any money off of generic levothyroxine, we have no stake in the game. I promise you. I would love, if you're describing
Sonia Singh MD:that is'cause you need it. I would love to know the root cause. I would love to have a dietary intervention to tell people about, to prevent their progression to hypothyroidism. That would be awesome. I think there's this perception of but then the doctor loses the customer.'cause then, they would be treated. But that is crazy. I will tell you the people, I'm sure you feel the same. 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. And just we want to help people and fix them. 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. So I think we covered, the main tests that are often requested by people who are wanting a full thyroid panel. 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. You have talked about what information comes from it, you have a qualified professional that's going to interpret it. You have talked about the potential cost to the patient. 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.
Rebecca Berens MD:Yeah. Alright, so I think we covered some of this already, but what can we learn from this as doctors and humans?
Sonia Singh MD:I think the biggest thing I take from this, which is often my take home is that. Patients are just craving a better understanding of what is happening in their bodies. 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. 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. 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. I think that's actually very common. That happens commonly where I think somebody comes or feeling something, the doctor does the labs, they're like, it's fine. And sometimes they drop it there and the patient has this perception that they're being told nothing is wrong with you. And the reality is if you are not feeling well. That is wrong with you. Something is wrong with you. 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. 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. 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. 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. I almost wished that you did because I know how to treat that. 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. But I think just pointing out that they're usually not touching at all upon how valid is this assay? How accurate is this assay? How does this translate in actual human beings and in clinical medicine? I hope people start noticing that a little bit more.
Rebecca Berens MD:Yeah. 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. And I know you probably do this, I always do this. We always have a follow-up appointment to talk about labs. Yeah,
Sonia Singh MD:yeah.
Rebecca Berens MD:Regardless of if they are normal or not. Because I wanna make sure you understand everything. I tested what it means, and then also does this answer the question we were asking when we got these labs or not? Or are there still symptoms? And I think there's so many reasons in the healthcare system that those follow-up visits don't happen. But my push is always for patients. 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.
Sonia Singh MD:Yeah. True. And
Rebecca Berens MD:I've, I, and because I feel like people would, you would know what was going on with'em. Oh, they're so busy. 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. So you may not remember oh yeah, that we checked this though because they were feeling something. Yeah. 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. Yeah. Yeah. You can easily miss things that way. And so I just would encourage patients if this is important to you. 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. And I'm sure that there's still lots of barriers to that and that's not, an easy answer for everyone. But I just encourage people like to, that isn't a self-advocacy step that you can take. To just go ahead and book yourself the followup appointment. Even if your labs were normal, make sure you feel like you understood everything. 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.'Cause it's just not gonna happen on the portal. It's just not yeah, like you just can't have
Sonia Singh MD:that kind of conversation on a portal. 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. It's very tempting to just be like, Hey, everything looks great. Send everything looks great, send. And like you said, you may not, remember that, oh my God, that person was feeling awful. So actually the message to say, Hey, I don't see any big red flags in your labs. How are you feeling? Let's talk about this again. When can you come in and see me? Yeah, I totally agree. That's great advice. 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. Sometimes I encounter these people in my meet and greets where they're like thinking about joining my practice. 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.'Cause as we talked about, like TSH is adequate for 98% of cases. But there's other diseases with the thyroid besides that. 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. 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. 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. 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. Yeah. Yeah, I guess that's my other 2 cents there. Yeah. Actually, you know what, I wanna say one more thing, which is. 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. 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. 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. 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. It is really to use large, pools of evidence and the consensus of the world experts on these topics to make those decisions. And so we're not gonna be right all the time. 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. And, they're what about me? You're just saying that all of this stuff doesn't make any sense and doesn't work, but it worked for me. So anyway, that's a finishing point that I wanted to make.
Rebecca Berens MD:Yeah,
Sonia Singh MD:absolutely. Okay. 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. We'll have our references also in the show notes and a few people on social media to follow for good evidence-based information. That's the end of our show. Hey guys. Last but not least, we have a very important disclaimer. This podcast is intended for educational and entertainment purposes only. 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. Listening to this podcast does not establish a physician patient relationship between you and the hosts. We are doctors, but not your doctors. Any medical topics discussed are presented for general informational purposes and may not apply to your individual circumstances. Always seek the advice of your own qualified healthcare professional regarding any questions you have about your health. Medical conditions or treatment options, never disregard or delay medical advice because of something you've heard on this podcast. 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. Please note that this podcast includes discussion of emerging research, evolving medical concepts, and differing professional opinions. Medicine is not static and information may change over time. We, the hosts make no guarantees about the accuracy, completeness, or applicability of this content, and we disclaim any liability for actions taken or not taken based on the information provided in this podcast by listening to the Antisocial Doctors Podcast, you have agreed to these terms. Thanks again for joining us.