Top 10 Things To Tell Your Endocrinologist To Make Her Cringe…

…and want to flee the exam room ASAP.

I do not take any pleasure in stating the obvious, but here goes: your Endocrinologist is a human being, just like you.  She has strong opinions, moods, stress, hot-button issues, biases, and bad days.  There are certain recurrent aspects of patient interactions that drive her absolutely insane; recognizing this universal truth, do what you will with the following insider tips, guaranteed to result in a terrible doctor-patient experience:

1. [Smiling beatifically while gazing soulfully into your doctor’s eyes] I am so glad to finally be here…

Allow me to set the scene: it’s your first visit with this doctor.  She’s probably already had a rough day by the time you make it into the office.  Knowing this, you want to set her mind at ease that this visit – your visit – is not going to be like the visits with all those other unappreciative patients.

Everyone enjoys a little flattery, no?  Your Endocrinologist certainly is not immune to it.  By all means, go ahead and express your profound gratitude for being in the presence of a kind, thoughtful, and thorough physician.  Make it clear that the Rheumatologist, Neurologist, Cardiologist, primary care provider, and the two other Endocrinologists you’ve seen over the last five years just weren’t that good at listening and didn’t seem committed to working with you to find an answer to the constellation of nonspecific symptoms that continue to plague you.

Emphasize that you’ve done your research, and based on patient reviews online, you know that this Endo is going to be your savior – your confidence is supreme and unwavering.

2. I just want to tell you everything, so you have all the information you need.

You’ve done your homework and know that this doctor is thorough.  She will review decades-worth of your medical history, while patiently listening to you explain every whiff of a possible symptom that you’ve experienced over that time frame.  Remember when you had that fleeting pain on the right side of your neck, once, 16 years ago?  Could be important.  Make sure you tell her everything.

It is critical that you get it all out on the table in the time allotted for the visit, so speak as quickly as possible, and don’t waste your brain bandwidth trying to relate anything in a chronological fashion.  Your Endo has gone through medical school, Internal Medicine residency, and an Endocrinology fellowship.  She’s been trained to sip from the fire hydrant, separate the wheat from the chaff – pick your metaphor – bottom line: if you vomit your entire medical history onto the exam room floor, she’ll deftly sort out what has made you ill, right?

Wrong.  She’ll cut you off, step out of the room, order a few lab tests just to get you out of the office, and when those tests come back normal, she’ll send you a terse note advising followup with your PCP.

3. I know my body…

Nobody knows your body better than you.  Sure, your Endo has seen hundreds or even thousands of bodies very similar to yours, but yours is special.  Different.  When something doesn’t feel right, there must be an explanation for it.  If your Endo hasn’t found it, it’s clearly because she hasn’t looked hard enough.  Reassure your Endo that you understand that your “normal” lab results may not be accurate, which is why your naturopath has been treating you based on symptoms – not numbers – with the shopping bag full of supplements you’ve brought along.

For bonus points, you can shave an extra few minutes off your visit by removing the supplements one-by-one from the bag, asking your Endo’s opinion about the utility of each (she’ll cut you off at bottle #2, turf the rest of it to her medical assistant, and tell you she’ll do some research on your supplements and get back to you – you’ll never hear from her).  To demonstrate ultimate mastery of visit-shortening technique, ensure that 80% of the supplements are herbals with at least 5 syllables in the name.

4. I am very sensitive to medications.

This is the corollary to I know my body…  Given that we’ve already established that you are special and different from the thousands of other patients your doctor has treated with the exact same medical condition, it’s not much of a leap to accept that the typical prescribed doses of medication will be too much for you.  Make sure your doctor understands that you view the prescription as a suggestion, not an order.  You have a pill splitter at home and will probably take 1/8 of that 25 microgram levothyroxine tablet for the first few weeks, just to make sure it agrees with you.  After all, the last time you took a single dose of 1/2 pill, you had two weeks of chest pain, insomnia, sweating, heavy legs, foggy brain, and visual floaters.

5. I don’t eat that much.  Everyone says I eat like a bird.  I eat way less than my husband/wife/boyfriend/girlfriend/friends/boss/housekeeper and I still can’t lose weight.

Your Endocrinologist needs to know that your diagnosis of hormonally-related weight gain is preordained.  It must be, because there has never been another person in the history of modern medicine who has eaten as little as you with zero to show for it on the scale.  When your doctor probes a bit by asking you more about what you’ve eaten in the last 24 hours, the correct answer is “I haven’t had anything since dinner last night, which was 3 ounces of grilled salmon with 6 asparagus spears, and water.”

Make it clear that the pizza, beer, and cake you had the night before last night was only because it was your niece’s birthday.  And the Big Mac with fries and a Coke you had for lunch last weekend was only because you were on a road trip.  Oh, and the venti mocha at Starbucks yesterday morning was a rarity, only because you had to take advantage of your free birthday drink coupon.  Under normal circumstances, you hardly eat anything.

6. I need my hormones checked.

You’re at an Endocrinologist’s office, so she should know exactly what you mean by that.  But if she does ask for clarification, explain that you “just haven’t felt right for a long time.”  If your doctor tries to draw you out further, allow your face to register irritation with how long this simple transaction is taking.  Make it clear that you just want her to order “the panel.”  For bonus points, bring a written list of all the tests you think she should order, based on what your sister (not a doctor) told you needs to be checked.  To 10x your bonus, make sure that your list includes at least one of the following: reverse T3, MTHFR mutation, or a 24-hour salivary cortisol profile.

7. I prefer to treat things naturally, without medications.

Explain to your Endocrinologist that you were quite happy with your naturopath’s care, and the only reason you’re back in the Endo’s office is because insurance would no longer cover visits with the naturopath.  Poo-poo your Endo’s concerns that your laundry list of “natural” supplements still need to be detoxified by the liver, and assume a dubious smirk when she explains that your nutraceuticals may actually be more harmful than the evidence-based, single medication that would directly address your medical condition.

8. Bitterly complain and perseverate for several minutes about the cost of prescription drugs like it’s your Endocrinologist’s fault…

…while simultaneously complaining that your Endo refuses to order hundreds of dollars worth of blood tests like your naturopath used to do for you every visit.  Refuse to see the irony when your Endo points out that your naturopath preaches treating based on symptoms (not numbers), yet that naturopath routinely orders 7 pages of labs not covered by insurance, then ignores all of the normal numbers and “treats” your symptoms.

9. Quickly shoot down every suggestion your Endo makes regarding what you could do to manage your weight/sleep/mood/energy.

You already explained to your doctor in the first 5 minutes that you’ve tried everything.  By making suggestions, your doctor is clearly calling you a liar; it would be advisable to truncate this futile visit as soon as possible.

10. Come back for a followup visit 1 year later.  Explain that you didn’t take the medication your doctor recommended because you read up on it and the side effects are terrible; you didn’t do the sleep study she recommended because you don’t want to use CPAP; and you didn’t do the followup labs recommended on the after-visit summary because nobody told you to.

At this point, your Endocrinologist will be cringing internally while asking how you’re feeling now.  It’s time to prove that you are the Zen Master of doctor-repelling: with equal parts consternation, accusation, frustration, innocence, and incredulity, you exclaim “I don’t understand why I feel just as bad!”  For a moment, just let the silence do the work.  Then, to really press your advantage, repeat the following at regular intervals, titrating the frequency of this statement to crushing of your doctor’s soul: “But there must be an answer!”  Game.  Set.  Match.

Are you a physician who recognizes any of the above?  Can you add a few more to make it a top 15 or a top 20?  What makes you want to flee the exam room?  What’s the worst interaction you’ve ever had in the room?  If you’re a patient, what are the top few things your doctor could do to make the visit better?

By interacting with me in the Comments, you agree that you have read and will abide by my Disclaimer.

49 Replies to “Top 10 Things To Tell Your Endocrinologist To Make Her Cringe…”

  1. This one was a bit hard to read, as I’ve certainly been guilty of 1 and 2 (after not being diagnosed or sent to a specialist for a long time by my GP, partially because back then I didn’t know how to quantify my symptoms, partially because GP overlooked test results). But it is good to know how I could improve my communication.

    “If you’re a patient, what are the top few things your doctor could do to make the visit better?” – it would have helped to get a recommendation about trustworthy information sources (this doesn’t require much time) or tips on recognizing quackery (could be quackwatch.org or something similar). In 9 years under endo/oncology care there was only 1 instance where after inquiring I was told about a decent EBM website where I could get read about my issues in a calm setting back home. There were no explanatory brochures and the short visits can only cover the current issues. The typical doctor’s warning “Don’t read anything on the internet” doesn’t really work, as I don’t know any patient who would not like to understand what is going on with him/her, especially when scary diagnoses are involved.

    This must be so much easier for doctors and patients in English speaking countries (plenty of good information available online) or in medical systems where there is some nurse or admin support after a doctor’s visit. I think sometimes doctors too hastily label the patient as a fan of alternative medicine and not worth educating, when he/she simply has desperately looked for information and unknowingly found an untrustworthy source.

    Had there been a blog like this, so much confusion would have been averted, so these posts will definitely help others out there. Hopefully other doctors can give this link to their patients.

    1. Thanks, BL. You make some great points here. From my perspective, in the U.S. there is a ton of reliable information on the web, but so many patients seem to gravitate toward the quacky sites that shout the loudest (e.g. “what your doctor doesn’t want you to know about your thyroid,” “why your doctor is an idiot,” etc).

      I can usually tell within the first few minutes of a visit whether a patient who appears to be into alternative medicine is going to be receptive to education from me. I will almost always attempt to educate, but if I get shut down by the patient, I may only make one more attempt during that visit before I decide to conserve my energy for someone I can actually help.

      For doctors who have even shorter appointment lengths than I do (I see new patients in 40 minutes, followups in 20 minutes), you are probably right that they are quick to label someone as a “fan of alternative medicine” and they may be more dismissive of that person.

      Some of my best interactions, however, are when someone comes in believing a bunch of quackery they read on the web, but they’re receptive to my opinions and I can see the light bulb go on above their head during our chat.

      Anyway, don’t beat yourself up too much about acting like my hypothetical (slightly hyperbolized) patient in this post. If you’re self-aware enough to recognize you’ve made a few of these moves, then you are WAY ahead of the game.

  2. How do you doctors endure these people?? Sure, slightly hyperbolized, but I hear variations of most of these things myself every day from people and it’s all I can do not to start a fight with them!

    1. AA, sometimes it is very difficult to hold my reactions in check. Over the years, however, I have trained myself to do a few things which help:

      – Even if I know within the first 30 seconds that I can’t help this person, I listen for at least a few minutes before trying to guide the conversation. People mostly want to be heard, even when I can’t help.

      – I remind myself, constantly, that this person is truly distressed and looking for answers, and I try to nurture that kernel of empathy, even when they’re driving me nuts.

      – I try to couch my counseling in such a way as to not provoke a confrontational reaction. I have gotten pretty good at telling people what they need to hear even when it’s not what they want to hear. That has taken YEARS of practice.

  3. Hi, just came accross this page and really enjoy it. Caught myself in some of the above points 🙂 so would be interesting to know how to bring across the points better then. For me quite a view of the above seem to be more miscomunication.

    This happens from the doctors side often as well
    E.g. doctors like to ask very unspecific maybe smthg. like
    So why are you here today?
    If you get the whole life experience or an answer like “You need to check my hormones” no wonder.

    Since it is not clear what you really want to know. More specific question will result in more specific answer.

    If you do not want allways the whole life story….hand out questionnaires before the appointment….you will get the information you need and the patient can fill it out without being nervous/stressed

    Or questions I hate are what were your symptoms… and it is months that had gone by since the last appointment….and you have more than one condition…. so it is constantly changing….and you did not figure out all health problems…. so which of the symptoms should I mention now?
    Maybe he mentions only 1 or 2 of the last view days….you draw a conclusion he considered or tried before with another doctor…and knows it did not work….and he knows there are still more symptoms he did not mention that do not fit what you suggest….but there seems to be not enough time to explain the reasons….or he is evem embarrassed to mention some of the symptoms ….so he might say “I know my body” instead.

    For me it is really an eyeopener to read your blog and see the “other side”. Please do not forget that we are also humans only and might have made bad experiences with doctors (e.g. forgetting to give necessary medications after operations because someone forgot to note it in the file) and are very aware that doctors are only humans too. So please forgive us if we might sometimes have second thoughts on your suggestions.

    I am looking forward to also read your other posts. Please keep writing!!!! It is smthg. patients need! And it is very kind that you take the time for it!

    1. Thanks, W! You make some great points, too. As docs, we need to remind ourselves that the person sitting in front of us is coming in at a vulnerable time (not feeling well), and we would do well to try to look at things from the patient’s perspective.

  4. Hi HG, thank you for the tips on how to be a less annoying patient. I’ve been working on being more concise with my doctors because I tend to be a bit of a worrier. But I do believe in evidence-based medicine, and I usually try to tell them that upfront. When I had a very long term bad stomach pain problem, I finally made a calendar and marked the symptoms and how they affected my daily life, and brought in about a month of that, typed very clearly, and just handed it to my doctor. Then he understood the severity of the problem, and ordered a more invasive test and actually diagnosed and cured the problem. That was after a few years of trying to get other doctors to take the problem seriously. I also like to ask “what do you recommend? “Or, ” is it possible that a person can have this symptom for no discernible reason, and it’s not anything to worry about? ” If the doctor says yes, I usually stop worrying about it. My pet peeve is when a doctor comes back with test results and says “Great news! The test came back negative!” This is great news if it was a test for something like cancer. But if it was a test for something curable like H. Pylori, and I still have a troubling symptom, this is not necessarily great news. When the doctor approaches me that way, I suspect that they think I’m a hypochondriac and they want me to go away. After reading this blog post, I guess I can understand why they might think that. Anyway, I really liked your articles. Thanks.

    1. Thanks, Srito. I actually do like it when a complicated patient types up a chronology for me that I can peruse before entering the room, as long as it is concise and stays on point.

  5. I have a complex medical history and multiple medical problems. I dread meeting new health professionals, particularly in an urgent or emergency care setting where the clinician is likely to be in a rush and I haven’t prepared for the encounter. If the practitioner hasn’t looked at my notes, even a succinct statement of my presenting complaint, other current health issues and relevant medical history will take a while. I am well aware that (see no.2) the doctor doesn’t need to know the equivalent of ‘I had neck pain once 16 yrs ago’, but I often struggle to estimate how much s/he does need to know. I am a fairly capable communicator, but I worry both that I am boring the practitioner with irrelevant detail and/or omitting something important. Add the fact that some of my problems were caused by a missed diagnosis of a medical error, which makes it hard for me to trust the profession. I appreciate that all this probably makes me the sort of patient that makes clinicians want to run from the room, but willingness to listen carefully, be understanding and clearly tell me what information you do need goes a long way to reassuring me that you will do the best you can for me. In return, I try to be a ‘good’ patient.

    As regards no.9, clinicians advice on these sorts of issues is often to do things like lose weight, exercise and reduce stress. While sound suggestions, these are often really hard to achieve. While I can understand why a doctor would be annoyed if a patient simply ‘shot down’ this sort of recommendation, I do think that they need to remember that they are hard to follow. I take the view that its better to honestly admit that I don’t think I’ll be able to follow a particular suggestion and explain why than to just smile and nod. That way the practitioner can perhaps suggest something that I can do, which is better for both of us.

    I think doctors need to remember that the patients that they see are (often very vulnerable) people and try to be patient themselves . However, physicians are people too and it must be hard to do that day in, day out. There are also very real grounds for getting angry with NDs and other ‘therapists’. They are, frankly, taking advantage of ill people by ordering unnecessary tests and prescribing inappropriate treatment. They also make doctors’ jobs more difficult by giving patients attitudes and beliefs that make it less likely that they will accept the actual diagnosis and treatment the MD gives.

    1. EP, your points are well-taken. It saddens me to hear that you “dread meeting new” doctors, but I can see why you feel that way. From my perspective, doctors should never enter the exam room before reviewing the chart, especially when the patient has a complex medical history. For tough patients, I sometimes spend 4-8 minutes before the visit reviewing the chart in detail, compared to the usual < 1-2 minutes it takes me for someone I know pretty well. During my history-taking, when patients don't seem to know what's important for me to know, I like it when they allow me to direct the questioning. Too often, I have patients who have problems that are at the top of their list, but those problems have absolutely nothing to do with Endocrinology. Though I want them to feel heard, I also want to ensure we have the time to cover the issues I can actually address. If they perseverate on their musculoskeletal/neurologic/other non-endo issues, that can make the visit very challenging. If patients don't know what I need to know, the best thing they can do is prepare a brief (< 1 page), chronological history, using mainly bullet points and trying to limit it to just the facts.

      1. Great suggestions! Just like EP, I dread going to a new practitioner, especially being an introvert, not such a great communicator, and not being sure where the distinction lies between important and non-important issues, as previously I’ve had a situation where a supposedly minor issue was what finally lead to a diagnosis.

        I recently had to start all over in a new country and deal with this in my third foreign language, so let’s just say it’s stressful 🙂 But what really made the difference was lots of clarifying questions, I felt like the doctor really paid attention and that I didn’t have to nervously think of anything I might have forgotten, because all the issues I considered important were already brought up by him.

        I suppose I’ve really overdone the one page approach. I usually take a folder with all the relevant documents in chronological order and divided in sections. First there’s a short case history with bullet points and meds, then, if the doc wants it, comes data in more detail and by specialty – endo, onco, gyno, further divided into pathology reports, US/MRI results, blood test results in chronological order, and 1 page of graphically displayed results of 4-5 main tracked blood test values from the past years with corresponding dates, so, if a particular value in particular time is necessary, it can be found quickly. When I met my new doctor, he made photocopies of quite a few pages, so I suppose it wasn’t useless.

        Still, I always wonder if I get labeled as the crazy patient when I arrive with this folder, but it calms me down, because I know I can look stuff up if I blank about some details in stress, e.g., when was which procedure done, when did value X start rising, when did I start or stop taking medicine X or Y, when was the dose changed, what is the name of this blood test in the language I have to speak today, etc. Apparently there is a name for this: la maladie du petit papier or the illness of the little papers: http://www.nejm.org/doi/full/10.1056/NEJM198509123131110, so it seems like I would be the dreaded “little nervous lady”.

        Having had serious issues that can recur does make me neurotic about forgetting something or not communicating clearly, so I feel very torn between this approach, that gives me a sense of control, and willingness not to be the annoying patient. Do you think doctors mostly look down on such a folder approach and I should try to appear more relaxed? Or maybe ditch the folder after the first visit – after all the doc took the history, so he knows all he needs already. But then again, maybe my regular doctor should also know that I’m neurotic, why hide it? Neuroticism doesn’t exactly exlude physical problems after all, does it?

        1. BL, when I don’t have access to all the original medical data via the Electronic Medical Record (EMR), I love it when patients bring in a well-organized binder of all their lab results, imaging, doctor notes, etc. I may think these folks are a little compulsive, but that is far outweighed by how helpful it is for me to be able to review objective data, as opposed to just hearing a description from the patient about what some doctor told them 5 years ago.

          I may only need that binder the first visit, because I usually extract the most useful data and dictate it into my note, so that I can refer back to that before every subsequent visit.

          But for general purpose visits, a short summary with bullet points is good for any doctor to have, especially if it is an urgent care visit in which the doctor doesn’t have the time to review a binder full of data.

  6. I’ve been to about 20 different doctors trying to figure out what was wrong with me. Every one of them told me I was normal. I told every one of them my symptoms. I even had a list of tests that I wanted to run, but they didn’t. They knew my body better than I did. Finally, 10 years later, I found a doctor who agreed to test for the things I wanted. It turns out I was right. If the first doctor had actually listened to me, my children’s lives, my life, my marriage, my home, my relationships would have been so much better. I finally got a correct diagnosis from a doctor who very patiently put up with all that you mention here. I think she probably understood that I am the paying customer, and she’s the service provider. I had symptoms that I thought were insignificant, so I never mentioned them. It turns out that those insignificant symptoms actually were clues to help diagnose me. I had no idea. I’m so glad I did list every symptom for my doctor. If I had played it safe, leaving out the minor details, she might not have connected the dots.

    1. Not 10 years later. That should read after 10 years of doctor visits. I saw about 2-3 different doctors per year trying to find one who would listen.

  7. And this is why I stopped going to endocrinologists. This is the typical stuck up, uncaring attitude that makes people go to naturopaths in the first place. You refuse to listen. You don’t think of people as individuals. Often, you use outdated “normal” ranges, especially in regards to TSH. You stopped learning after you got your degree. THIS is why Leana Wen’s Who’s My Doctor campaign is important. If most thyroid patients read this blog, they would probably never visit your office again.

    1. Amanda, I’m glad you left this comment. I can absolutely see how people would be offended by this post. I’m going to push back, though, and suggest that perhaps some of that offense is because people see themselves in these examples. What’s our most common reaction when someone criticizes us? We get defensive and lash back.

      Everyone who reads this has a choice: they can dismiss me as an insensitive jerk who isn’t fit to take care of patients, or they can view this post as a gift. It’s a gift because it actually gives you a rare view into what your doctor is actually thinking, and it tells you how to navigate the relationship to make it more productive. This is essentially a blueprint for how to get more out of a visit with a doctor.

      I may not be able to convince you, Amanda, but I hope others will choose to view this as an opportunity instead of an obstacle.

      1. Most patients have had to fight tooth and nail just to get a referral to see and endocrinologist. You better believe we are happy to be there. We have felt lousy for so long that you’re our light at the end of a very dark tunnel. We don’t want to be there. We’d love optimal thyroid function. It gets hard when we have tried so much and chances are many of us knew something was wrong and even told our docs. I’d think after dealing with so many patients suffering from thyroid issues, you would understand that we are at the end of our rope. We offer this info because it’s been ignored before. I wonder if you physically felt how we do if you might have a slightly different opinion. I understand you are medically trained for this but people with thyroid issues also suffer mentally. Knowing this , it seems you would be a bit more understanding when you do encounter an overzealous patient.

        1. I do understand your points. I don’t really have a problem dealing with overzealous patients at the end of their rope, as long as they are willing to listen to reason.

    2. Absolutely this.
      Any doctor or Endo that is going to stick their nose up, get annoyed, not give the patient a call back or return letter, follow up or basically anything to the detriment of the patient, including cringing openly, doesn’t deserve that job, no matter whether the patient is right or wrong in doing some of these things.
      The medical professional is there to guide the patient and not just give advice. Many patients are doing this for the first time and on top of that it can be immensely frustrating when being passed on to other professionals who don’t know your history and give poor advice because of that.
      If a professional has an expectation like these points then the patient needs to be given literature to that effect before consultation and the professional needs to do some homework. Put these two things together and no one will be cringing.

  8. I understand both view points in this debate. I am someone who works in the medical field and understand the importance of double blind studies to investigate the pros/cons of medication and treatment of thyroid disorders. I have encountered my fair share of crazy patients who blame everyone around them and don’t listen to professionals. Unfortunately, I believe that the treatment of thyroid disorders is sadly insufficient. I have a “renowned” endocrinologist who spends only 5 minutes with me, shoots down everything I try to present to him, and prescribes levothyroxine. The majority of women who suffer from thyroid disease struggle with weight, depression, miscarriages, hair loss, muscle pain and countless other symptoms. It would be nice to talk to a doctor who understands that unbalanced hormones often lead to unbalanced people. Also, I think diet is a huge component to treating thyroid disorders and wish endocrinologists were more willing and accepting of using food and supplements as a form of treatment.

    1. Thanks for your comment, Carrie. It’s very frustrating to get 5 minutes with a doctor who doesn’t appear to be hearing you. I am going to push back a little bit about your statement that “the majority of women who suffer from thyroid disease struggle with weight, depression, [etc].” I don’t find that to be true; rather, I think the majority of people with thyroid problems are adequately treated by their primary clinicians and never show up in an Endocrinologist’s office. And, many times, persistent “thyroid” symptoms are not actually due to the thyroid – they’re due to something else that has not been diagnosed or treated adequately.

      As for diet and supplements for the thyroid, I would say that the research in that area is unimpressive. Amanda’s claim that I “stopped learning” after getting my degree notwithstanding, there just isn’t any credible data showing that you can “eat for your thyroid” or that there are supplements that make a big difference (unless you are truly iodine deficient or selenium deficient). I think that when people start eating better, in general, they feel better. That’s where diet comes into play, but it doesn’t have much to do with the thyroid.

      1. My primary Doc did nothing but prescribe me levothyroxine. The drug the Pharmaceutical Companies have brain washed all you Endo’s into believing synthroid is the one magical drug. It doesn’t work for a good chunk of thyroid patients. You don’t listen. NDT’s is a great treatment for most of us. And the majority of Endocrinologists won’t prescribe it. And diet is a big thing with thyroid patients . Most of us have hashimoto’s disease which most of you Docs just totally dismiss because you can’t treat it. We treat it with…. diet. You don’t listen. Once I found a Doctor who prescribed Naturethroid, wonderful things happened. My hair and nails started growing again, I lost 20 pounds over several months. My brain came out of that fog. And I once again had energy. So I will never go to an Endocrinologist or any other Doctor who will not listen.

          1. Lots of reasons:

            1. It usually doesn’t work.
            2. If it does work, the effect wanes over time, suggesting that it was a stimulant effect and not a true need for T3 replacement.
            3. Years of dogma telling us nobody needs T3.
            4. Not wanting to be mistaken for a quack who hands out T3 pills like they’re M&M’s.
            5. Patients often have other conditions that are more likely to be causing their symptoms, other than uncontrolled hypothyroidism.

            As I explain in the T3 article, though, there are occasional patients who truly benefit from it.

  9. In regards to your point about persistent thyroid symptoms not actually being thyroid symptoms, in your opinion are there any other conditions that frequently occur with Hashimoto’s patients that we could be mistaking for a thyroid problem? I realize this is not the job of an endocrinologist, but I’m curious if by chance you have seen any trends? Also, I completely understand your point #5 above about poor eating habits, but surely there are exceptions. I assure you I haven’t had a cookie, soda, Starbucks drink, or sugary treat in a number of years (no exceptions, not even birthdays or holidays). I don’t eat processed food. Any carbs I eat are from sweet potatoes, or other starchy vegetables. I eat minimal fruit. Still, I know I don’t eat perfectly (perhaps I eat too MANY healthy things), but the wording of your point #5 seemed a little harsh. I don’t disagree that you see a lot of those types of complaints from patients in your practice, but some of us really don’t eat those things you talk about and aren’t stretching the truth about our diet when speaking to our doctors. Still I appreciate seeing your point of view and perhaps taking your other points into account for future appointments.

    1. Alice, there are lots of things that can coexist with Hashimoto’s – sleep apnea, primary depression, other autoimmune diseases…the problem is that Hashimoto’s is so common that almost anything can coexist with it, making it difficult to know whether someone has inadequately treated hypothyroidism or something else. Until we look at blood work, of course.

      As for diet, I agree with you. I know there are people who really are eating 1200 calories per day and exercising 5 days per week, and are not losing weight. Those situations are always very tough to sort out.

  10. I was going to the same GP for 15 years! I’m sure in his notes he had 30 of my symptoms . I certainly had them all written down. You would think he might’ve actually sat down and read them to give me a diagnosis? Instead it would be “now you have an iron deficiency”! No that is not possible!
    One visit with a naturopath she asked me to tell her about my health history and within 15 min she predicted I would test positive for celiac disease and sent me for tests! Fifteen minutes into meeting her!
    The difference is SHE LISTENED!
    She also thought I might have Hashimoto’s Thyroiditis. She sent me for that test also. Positive!
    She was correct on both predictions and changed my life!
    Then I proceeded to go to an endocrinologist and explain to her that I’m celiac and I’m overweight and have Hashimoto’s. She tells me that taking meds for my thyroid problem is not going to help my weight. I need to go on her diabetes diet!
    Breakfast: whoke wheat toast!
    I asked her if she understood that I had celiac disease and couldn’t eat wheat? She said “what’s going to happen”????
    You wonder why patients come in with long lists and pages of their own health history?
    You have to be in control of your health because I’ve been disappointed way too many times with doctors that were highly recommended!
    And just sometime if you LISTEN to your patient you will learn something that will be the answer to the proper diagnosis!

    1. I agree, Andrea. We absolutely should be listening to our patients, or we will not likely reach the appropriate diagnosis or treatment plan.

  11. I’ve been to one endocrinologist who told me there was nothing that can be done about my thyroid antibodies. NOTHING. He told me “you shouldn’t be tired” over and over like my chronic fatigue was my imagination.
    After this visit I saw my future looking like my mother’s and older sister’s – hypo/hyper – and all the crap that comes with it.
    Coming from a research background I decided to look into things. And there IS a treatment! Low Dose Naltrexone. There is research and evidence that it can lower the immune attack, prevent, and occasionally reverse hypothyoidism. Why didn’t my Endo know about this? Is it because Naltrexone is not sold in the 4.5mg amounts needed, and so not promoted to doctors by pharmaceutical companies?
    I am now on it (thanks to a functional Dr) and my chronic fatigue has lifted! I also sleep better at night and have lost weight. No I’m not dosed up on supplements. Just Vit D and Iron. There is hope for me now.
    I want to believe endocrinologists do the best they can for their patients, but mine didn’t!

    1. Please cite the medical journal articles proving that LDN is effective for hashimoto’s and I will be happy to review them and give my thoughts.

  12. i’d add the potentially cringeworthy statement of a newly established patient in whom you’ve diagnosed some condition: “i’ve been reading about my condition on the internet and…” 1. a lot of people don’t like the drug you’ve recommended, 2. people say that their symptoms are different than mine, 3. etc.

    you’ve mentioned in other posts the patients who consult dr. google. i like to warn patients when i make a diagnosis, telling them to consult only the websites of medical institutions, not patient forums. the only people on patient forums are the newly diagnosed and those who are doing poorly. people who are doing well have better things to do.

    1. Amen to this:

      “i like to warn patients when i make a diagnosis, telling them to consult only the websites of medical institutions, not patient forums. the only people on patient forums are the newly diagnosed and those who are doing poorly. people who are doing well have better things to do.”

      I also completely agree with your #1 above. When I see patients for osteoporosis, if they haven’t already read that all bisphosphonates (like Fosamax) are evil, I try to preempt the call I’m sure to get later by addressing all the myths up front.

  13. This was a great read, but sub in “Endo with “ER doc” and you’d be surprised how little the dialogue changes.

    I work in a peds ER and so it’s the parents of the child who generally come in loaded with information and diaries re: to chronic complaints that acutely worsened and who want to discuss it all in-depth in the ER.

    For many of them I have a great deal of empathy because their child really does have some ongoing (usually very occasional) severe symptoms, or even if the symptoms aren’t severe, the parent simply isn’t equipped to handle what they’ve been told.

    However there are some who show up expecting a magic cure and us to fix them. That’s partially because I work in a freestanding children’s hospital that’s affiliated with a large university, so we have a reasonably good reputation and generally our hospital/clinics ARE where people end up when no one else can figure things out/handle the patient (or when the patient has decided they need someone else).

    However I do have it much easier in the ER in some respects, because I can be honest with them and tell them that it’s extremely unlikely that I am going to fix their chronic problem in the ER, particularly when they’ve had an extensive workup. I don’t order fancy random send-off tests from the ER unless a specialist asks me too, so I am able to tell them that they really will need to see that specialists (you — Endo doc) to delve more into the issues.

    I am not trying to turf the problem, but an ER is what it is, and most of these problems cannot be solved where I work (whether it’s through discussion or diagnostics). I will usually discuss it on the phone with the relevant specialist to see if they have advice; in some circumstances we’ll admit a patient if the specialist agrees/recommends it, but otherwise we focus more on reassurance/safety (i.e. whatever it is, you aren’t going to die before your clinic visit, and if necessary we’ll do some precautionary testing to ensure we’re not missing something big).

    1. Thanks for sharing your ER perspective, Rogue Dad. As an ER doc affiliated with an academic institution, do you need to worry much about Press Ganey/patient satisfaction scores? If so, does part of your salary depend on it? I ask because my impression of my academic colleagues (I am private practice) is that they don’t worry much about telling patients, “this isn’t an endocrine problem” and sending them expeditiously back to to their PCPs. They seem to be more insulated from certain “expectations.”

      1. Our hospital does obtain patient satisfaction scores from randomly selected ER patients, however they use it as a goal for the entire ER. They’ve never given individual physician score feedback, nor do they sample enough to do so.

        Given the amount of doctors/NPs in the ER, it would be extremely difficult to obtain enough scores to provide everyone accurate feedback. In a single week there are going to be 10-20 doctors + NPs that work in the ER. That doesn’t include the fact that there are med students, residents, and fellows in the ER interacting with the same patients before/after me. It would be almost impossible to get accurate scores for me alone.

        Additionally, ER satisfaction is significantly influenced by other things, such as wait times, nursing interactions, etc. that I have nothing to do with or can’t control. Patients perception of my performance is influenced by those factors, whether or not they realize it. I am sure that’s the same for your clinic — if the receptionist is rude to the patient your score is probably lower, and you may never know the registration person pissed someone off.

        So no, our salary is not dependent on that at all. We do have a small bonus that’s dependent mostly on clinical RVUs and academic productivity (I’m a university employee), but it’s not significant.

        Or to answer your question more directly — I am insulated in that regard. We get individual patient complaints sent back to us for review and discussion with our boss. While sometimes it requires outreach to the aggrieved party (or educating us on how to avoid it in the future), it currently has zero impact on my income.

        I am thankful for that, however given that my salary is much lower than it would be were I in private practice (there are private ER groups and non academic hospitals where I could get paid much more), I also expect some benefits in return for the lower salary.

  14. I’ve just discovered your blog and I think I’m in love!

    Your list overlaps significantly with my internal medicine experience.

    I’d add a few:

    1) Tell your doctor that you have a “high pain threshold.” That way your doctor will immediately know that you want narcotics and can show you the exit.

    2) Tell your doctor that you prefer doctors who treat things “holistically.” That way she can quickly say that she’s a reductionist, so this relationship will definitely not work out.

    3) Use the terms “chronic Lyme’s disease” (not Lyme, always Lyme’s) or “systemic candida.” Then watch your internist’s eyes fill with tears of despair.

    4) Send your doctor a 3 page letter after your first visit outlining how amazing she is, how no one has ever, ever listened to you the way she did, and how you have total faith in her and her ability to treat you.

    #4 happened to me a couple of years ago. I read the letter, and then asked my medical assistant to put it in her chart so I could use it when she filed a board complaint against me in a year or so. Sure enough, one year later….

    5) Call your doctor by her first name the first time you meet her. Even better, refer to her by her first name when making the appointment. For bonus points, tell her she should smile more, and then call her “sweetie.”

    1. This is good stuff, PCD. You’ve clearly been around the block a few times if you had the foresight to scan #4 into the patient’s chart. I, too, have found that the positive predictive value of such a letter for borderline personality disorder is about 97%. A brief note of thanks is always welcome, but what you describe gives me that feeling in the pit of my stomach – you just know things will go south soon enough.

      I know a couple of female docs who will give you an “amen” on #5.

  15. Oh yeah. That particular patient had a nice touch of Munchausen’s, in addition to her borderline issues. She was allergic to bee stings, and, no joke, got “stung” on a weekly basis. She’d always hit herself twice with the Epipen, and then when EMS showed up she’d claim to still have trouble breathing and they’d hit her again. Of course, then she’d end up in the hospital with tachycardia and hypokalemia. Not surprisingly, no one ever actually saw evidence of the “sting”.

    She filed the complaint because I refused to work up her hypokalemia, which was only present after she used the Epipen. I told her to stop giving herself multiple injections and to call a professional to deal with her bee problem.

  16. I just found this blog and I really like it!
    Now luckily I have not had any serious issues so far, but my recurrent issue with doctors is that they claim they practice EBM but when asked for evidence give a mechanistic explanation (which I cannot evaluate since I am not a specialist) or draw from experience. So they kind of want to have it both ways. Latest case:
    When doing fertility treatment (IUI), my doctor told me not to exercise until my pregnancy test (for about two weeks). No running, no weight lifting. Asked why, he responded that my body needs all the energy to make the embryo implant and grow (or something along those lines). When asked what evidence is there that this is true, he just repeated the assertion. I asked again for any pear-reviewed studies, even retrospective. And he repeated the mechanistic explanation. And I just let it go and went running the next morning. Because, what I could dig up, there is no evidence to support his claim. So in this sense, I am a bad patient because I did not follow my doc’s advice. But also he did nothing but use his authority to convince me that I should follow his advice.

    And this repeats over and over again. I cannot judge the proposed mechanism of action as I am not an expert. But if you tell me, “these are the studies that confirm my assertion”, I can look at them and at least evaluate how good are they from the statistical standpoint. It rarely happens. It is usually the line “trust me, I am a doctor”. Any doctor’s explanation sounds just as plausible as any quack’s explanation. And I do not believe the argument of authority. What makes a difference is the evidence in literature. Now I understand that most of the time, the doctors don’t have those studies in their drawer ready to go. They are busy and need to see other patients. Perhaps send me an email later with links? Have it ready for my next follow up visit? What is your experience with patients like me? Am I asking too much or perhaps in a wrong way?

    1. One thing I’ll say right off the bat is that not all fields lend themselves equally to EBM. Obstetrics/fertility is one of those. For many questions in that field, it’s not ethical or practical to do randomized, double-blind, placebo-controlled trials in pregnant women. So there tends to be a lot of voodoo. Does bed rest really work for all the conditions they recommend? Who knows? But if you’re pregnant and something looks wrong with the fetus/growth/etc, you’re probably going to do whatever the doctor says, within reason.

      I think asking for evidence is reasonable, but like you said, docs won’t necessarily have references in the drawer ready to go. And they probably don’t have time to find those references for you after the visit, though it would be lovely if a doc would go out of her way to do that for you. Our knowledge is based on having read hundreds or thousands of articles over the years, and we don’t always remember how we know what we know, or where we got that info. I think that’s why clinical practice guidelines are handy tools, because if you really want to know the evidence base for a recommendation, the CPG will refer to all the original papers on which the recommendation is based.

  17. After reading this I wasn’t sure if I should cry or laugh. ( I ended up doing a little of both!) I always refer to myself as the “dorky over-prepared patient that doctor’s probably hate listening to.” As a patient with somewhat of a complex medical history (I test positive for Sjogren’s Syndrome but have never developed symptoms of it, my TSH has been up and down for years and years and I also bounce back and forth from being anemic to being “ok”) I somehow allowed myself to trust in the fact that my Dr. is a well-trained professional, he’s been looking at my blood work results for years and he must believe that I’m ok after evaluating everything. As a result of this trust, I was anemic for years and didn’t even know. I complained about debilitating fatigue for YEARS while he watched my hemoglobin sit at 9 and 10 and my iron saturation level at around 11%. He said nothing and I missed major life events with my family because he chalked up my profound fatigue to me “having some type of autoimmune disease.” He watched my TSH go up to 5.0 down to normal range and never told me this probably wasn’t normal because I suppose he believed it was. It wasn’t until I accessed my blood test results online myself that I discovered I had not been ok for years. Am I a medical professional? Not at all. But I do know that hemoglobin at 9 and TSH at 5 can certainly be a reason for someone to experience some pretty significant fatigue. So now I’m left with having to find a new Dr. and start from square one with my history. Sadly (for me), I’m the patient you want to run away from. I have to walk in with the binder of info. knowing you don’t really want to see it, I have to explain that I have some unidentifiable autoimmune disease. I have to explain that what I’m experiencing isn’t rheumatological (according to my Rheumatologist anyway), I have to (as gracefully and tastefully as possible) try to plead with you to understand that whatever I’m experiencing is affecting my every day life now because the fatigue is unbearable. I have to ignore it when you say that I “look very healthy” and maybe I’m depressed. (Sigh…)

    There’s nothing like seeing the look on a doctor’s face once they’ve “checked out.” That’s when I stop talking because I know they won’t care. I take my Synthroid, eat well, exercise as much as I can and I hope for the best but I still feel terrible… so I’ve resorted to looking at web-sites full of quackery the past several months. I’m so desperate to feel normal. I went gluten free for four months and felt no better and I was about to order adrenal support supplements when I found your blog. It’s been very informative, so thank you for doing this. This particular post made me sad although I already knew it was true because I’ve experienced it. I understand your point anyway. If I was a Dr. I’m sure I’d feel the same way. I don’t believe the quackery. I don’t believe adrenal fatigue is a thing (I have all the symptoms of it so I almost wish it was) and I have never seen a Naturopath. I believe in evidence-based medicine. But… I do believe you should know that people like me, desperate to feel well, feel dismissed and uncared for when we can tell that all you want to do is leave the room and get to another patient. I want you to know that we cry the whole way home knowing that your suggestion of “get some exercise and make sure you’re taking your iron and multivitamin” won’t be enough. I want you to know that we fear and wonder if you’ll notice abnormalities on our blood work because someone else ignored it. While many doctors have seen hundreds or thousands of bodies as you stated, every single body is different. I DO know my body best. Only I know what I feel like on a daily basis. I AM different. I don’t fit the criteria for any one illness. I am not a textbook case. (My Rheumatologist says I have Hashimoto’s and my Endocrinologist says I don’t…) According to my blood work I should feel ok but I feel anything but. I am not depressed. I do not suffer from anxiety. I have a host of unexplainable symptoms and all I, and others like me want is to feel well. We want to feel that you hear us; that you care. Just so you know… we can tell you want to flee the exam room ASAP and it breaks our hearts. You move on and we leave, again, without the answers we’re desperate for.

  18. I feel like you have gone deep into my soul and have felt my pain. As an endo, I can relate to every single one of these. I’ve read a few of your posts and you so eloquently put into words how I feel at the end of a long, soul-crushing day.

    I, too, die a little on the inside when I’m the 3rd endo and 8th specialist they’ve seen who can’t seem to figure out why all their tests are normal yet they still feel tired, etc. Especially when they’ve been reading the blogs about how endocrinologists don’t know how to interpret blood tests, so whatever the endo tells you will be wrong, anyway.

    PrimaryCareDoc above also has some pretty solid suggestions.

    I’ll share a little something that will hopefully brighten your day. Recently my colleague received a referral for a patient who requested a “panhormone scan”. 😂 Thankfully I haven’t seen that one yet!

  19. Pt- “I want you to check my hormones”
    Me- “What hormones are you referring to?”
    Pt- “You’re the doctor, you should know!”

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