Revolutionizing Thyroid Care with Dr. Ruchi Gaba
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🎙 Episode 4 | Endocrine Matters Podcast
In this episode of Endocrine Matters, we welcome Dr. Ruchi Gaba, an Associate Professor of Medicine at Baylor College of Medicine, renowned thyroid expert, and thyroid cancer survivor. Dr. Gaba shares her unique perspective on thyroid care, shaped by her personal journey of navigating a near-missed thyroid cancer diagnosis and her work as Director of the Thyroid Therapy Center at Baylor.
Join us as we explore the challenges in thyroid care, the importance of patient-centered endocrinology, and how endocrinologists can rebuild trust with their patients. This episode is a must-listen for healthcare professionals, thyroid patients, and anyone interested in better understanding the complexities of thyroid health in today’s medical landscape.
Listen to the Full Episode
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Key Topics & Timestamps
Skip to specific parts of the episode:
03:12 - The Importance of Listening to Patients – How thoughtful listening and empathy transformed Dr. Gaba’s approach to care.
06:45 - Challenges in Thyroid Care – Why nonspecific symptoms and a TSH-centric approach can leave patients feeling dismissed.
10:30 - Diagnosing Hypothyroidism – Key tests for hypothyroidism: TSH, free T4, and free T3. When additional testing like reverse T3 is necessary.
15:20 - The Role of T3 in Treatment – When T3 therapy can benefit hypothyroid patients, and why it’s essential to use it responsibly.
21:00 - The Dangers of Overtreatment – Potential complications of unnecessary thyroid hormone therapy, including cardiovascular risks, anxiety, and bone loss.
25:40 - Addressing Misinformation – Navigating the challenges of alternative practitioners, supplements, and patient misconceptions.
30:55 - Functional Medicine and Patient Support – Acknowledging the value of functional medicine while ensuring evidence-based care.
35:10 - Shared Decision-Making and Trust – Building trust through empathy, education, and collaboration with patients.
40:00 - Holistic Approaches to Thyroid Care – How lifestyle, nutrition, and referrals to other specialists can complement thyroid treatment.
Episode Highlights
Key Takeaways:
Listening to Patients as Whole People – Dr. Gaba shares how her experience as a thyroid cancer patient reshaped her approach to patient care.
Complexities of Thyroid Care – Understanding hypothyroidism, its nuanced symptoms, and why a TSH-centric approach isn’t always enough.
Testing and Diagnostics – The role of TSH, free T4, free T3, and when additional tests like reverse T3 may (or may not) be useful.
The Role of T3 Therapy – Exploring when and why adding T3 to treatment plans can benefit certain hypothyroid patients.
Addressing Misinformation – Challenges posed by alternative practitioners, overemphasis on supplements, and unproven therapies. Dr. Gaba shares strategies for guiding patients through the noise of misinformation.
The Importance of Connection – How endocrinologists can rebuild trust with patients by focusing on empathetic listening, patient education, and collaborative decision-making.
Dangers of Overtreatment – Potential complications of excessive or unnecessary thyroid hormone therapy, including cardiovascular risks and bone health concerns.
Leveraging Functional Medicine Strengths Responsibly – Recognizing the value of nutrition and lifestyle counseling while addressing the lack of standardization in some alternative practices.
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Ruchi: [00:00:00] Now, I actually take time listening to my patients. Not that I didn't listen to them first, but this is a different kind of listening. This is very thoughtful listening. I'm actually, like, listening to them, not as a symptom or a disease. But like as a whole person, because that's what I felt. I felt and heard as a person when I reached out and requested certain testing, which were denied initially.
So definitely that whole experience has made me just pause and just reflect on how we are listening to our patients. Yes, we're making notes on everything that they're saying objectively. But take that moment to, to hear them out as a person to say, you know, so I think that really helps. Number one.
Arti: I'm incredibly excited to welcome Ruchi Gaba, MD, to the podcast. Dr. Gaba is not only an academic endocrinologist and a renowned thyroid expert, but [00:01:00] also a thyroid patient herself. She brings a unique perspective to the table, sharing her personal story of navigating a potentially missed thyroid diagnosis and how advocating for herself transformed the way she approaches patient care.
Thyroid care, especially for conditions like hypothyroidism, is challenging and complex. The experience of thyroid patients is Often highly individualized, making it difficult to standardize care, yet traditional endocrinology training has sometimes failed to fully embrace or address the nuanced and varied experiences of thyroid patients.
This gap can leave patients feeling dismissed and frustrated, compounding their health challenges. Endocrinologists, too, face significant hurdles in providing the care they know their patients need. The U. S. healthcare system often prioritizes volume over quality, placing time constraints on patient visits and limiting our ability to dig deeply into the root causes of thyroid dysfunction or the broader impacts of these conditions.
This fractured system strains the [00:02:00] critical relationship between patients and their endocrinologists, leaving both sides feeling underserved. On top of this, we live in an era where patients are more informed than ever thanks to the proliferation of information on social media and the internet. While some of this content empowers patients to advocate for themselves, much of it spreads misinformation.
Patients often come to us feeling confused or even harmed by advice from unqualified thyroid care providers who promote overly simplistic or ineffective treatments. This creates a dual challenge, addressing the medical condition while also rebuilding trust and dispelling myths. Dr. Gaba and I will explore these pressing issues and discuss how endocrinologists can navigate these challenges to deliver more empathetic patient centered care.
We'll also touch on how patients can better advocate for themselves and find the right balance between traditional medical care and the abundance of advice available online. This episode is a must listen for endocrinologists. Healthcare [00:03:00] professionals and anyone touched by thyroid conditions, who wants to better understand the complexities of thyroid care in today's world.
I hope you enjoy the show, and if you're looking for links to anything we discussed, check out the show notes
today. I have Rucci gaba. She is an endocrinologist, and. Just so, so incredibly compassionate, well spoken, and it is always clear anytime that she speaks that her heart is with her patients. And I am so excited to have her on our show today. We'll be talking about thyroid and how patients can get confused with the Onslaught of information that's available online as well as the challenges that our healthcare system pose to patients struggling with nonspecific symptoms, sometimes related to the thyroid or not.
And Ruchi is [00:04:00] really going to walk us through some of that and encourage us to investigate our patient's concerns as well as tell us how we as endocrinologists can perhaps do a better job to get our patients the best education that they need about their thyroid and get to really feeling their best.
So, Ruchi, welcome. Would you please introduce yourself? Give us a brief intro of who you are, where you work, what you do, and what brought you into the field of endocrinology, specifically taking care of thyroid patients.
Ruchi: Of course. First, I'd like to begin by saying thank you for having me. I'm very excited to be talking to you about something that I'm very, very passionate about.
Um, but I am an Associate Professor of, um, Medicine with Endocrinology, Diabetes, and Metabolism at Baylor College of Medicine in Houston, Texas. Uh, I also run the Thyroid Therapyroid Center, which is a [00:05:00] multidisciplinary center here at Baylor, where we manage like complex thyroid disorders and advanced thyroid cancer.
And I'm also the Program Director for our Friendship Program here at Baylor. Talking about what got me interested into endocrine. So my journey into endocrine, um, it's sort of like cliche, like, you know, the, the fascinating blend of these endocrine diagnostic challenges that we, um, come across in endocrinology and then the impacts in patient care that we often end up giving.
So of course, all of those like driving forces, when I initially chose endocrine to subspecializing. Uh, but specifically talking about thyroid, I think, um, my journey into thyroid has been very, it's deeply personal because, you know, I was diagnosed with thyroid cancer when I was in the middle of training and, uh, I was almost going to be misdiagnosed and, uh, get the wrong treatment or management plan for myself, uh, when I figured out that I needed to maybe do something more in this field, uh, create a center of excellence or something [00:06:00] that I could do to contribute to thyroid cancer.
So that's how my journey into thyroid Basically started and, uh, when I joined as faculty, they were looking to revitalize like our section was looking to revitalize the viral affinity clinic. So it was just like, that's awesome. Like that, that's, I'm going to do that. And so, um, that's how it all started.
Arti: Wow. I never, I never had heard that story and I actually didn't know that. So thank you for sharing. Would you mind telling us your story and what your experience with potential incorrect diagnosis was like for you as a patient?
Ruchi: Absolutely. So, um, in our first year of training, or I think maybe in our second year of training during endocrine fellowship, we often will do a course where we practice ultrasounds on each other.
So it was just a regular practice session with my co fellows. And, uh, one of them pointed out that there was something that they thought was looking interesting and I said, Okay, I'm going to get to it once I, you know, once I have some time. I didn't pay too much attention at that time. Uh, but once I graduated, I was [00:07:00] like, okay, I'm going to catch up on on my medical health.
And I took an appointment, did a proper ultrasound, went for a biopsy. Uh, and of course, I had like papillary thyroid cancer on cytology. And so because I had been trained, you know, I was like, okay, I'm ready for this, but not, not really, you know, cancer is a, it's a, it's a devastating diagnosis, I think, and no matter what knowledge and whatever you're equipped with to handle it, you're really not.
And so I was, I was the patient, I was on the other side, so very different perspective starting right there as the patient, because I got a call from my, in total medicine like my PCP who told me oh do not worry it's a very teeny tiny cancer we're going to send you in for a lobectomy and you'll be fine.
And, you know, um, and I said, okay, I said, maybe we should like investigate more because I had trained in endocrinology, I was like, maybe we should look for lymph nodes in the neck and make sure nothing else is going on. And so I went for a more detailed, I requested a more detailed ultrasound to [00:08:00] look for any lymph hypnopathy or lymph nodes in the neck.
And there was one that looked very, very suspicious. And so the plan from going from just to see your. Surgeon, do your lobectomy, get that half a lobe out. Now change to, okay, we need to take the whole thing out, plus do a neck dissection where we're looking for lymph nodes specifically. And so I think I sort of advocated that for myself, but if I had not had that educational, like medical knowledge or background, then I would have had a lobectomy done and the lymph node would have totally been missed.
And, uh, I'd hate to think about what would have happened next if that would have been missed. Um, but pretty much that's what happened and I got the right treatment. And this is going to be my 10 10 years cancer free, so doing great. Uh, so it's all behind. But it definitely gave me a very unique perspective and shaped how I think about patients and their experiences and my interactions with them.
Arti: Well, that is certainly something to celebrate, 10 years cancer free. But that [00:09:00] is, it just makes the whole healthcare, the problems that our patients face so clear, right? Because we're in this incredibly privileged position To be physicians and to know when we need to advocate for ourselves. Especially when I mean, you're an endocrinologist and you still had a misdiagnosis or a missed diagnosis.
Imagine if you were a patient who had never even heard the word papillary cancer before. You would have no idea to advocate for yourself, and that's 99% of people out there. Not that many people are an endocrinologist and and know to look for lymph nodes and. Clearly, your primary doctor didn't even know that and it's not even their fault, right?
Like, we don't learn that in internal medicine training. I didn't know anything about thyroid cancer before I became an endocrinology fellow. You [00:10:00] said that shaped your, um, shaped how you think about patients. Tell us more about that. How, how did it shape how you think about patients?
Ruchi: So how it changed my perspective was that now I actually take time listening to my patients.
Now that I didn't listen to them first, but this is a different kind of listening. This is very thoughtful listening I'm actually like listening to them not as a symptom or a disease But like as a whole person because that's what I felt I felt and heard as a person when I reached out and requested certain testing which were denied initially So definitely that whole experience has made me just pause And just reflect on how we are listening to our patients.
Yes, we're making notes on everything that they're saying objectively, but take that moment to, to hear them out as a person to say, you know. So I think that really helps, number one. And not to be dismissive. You know, often we know more than them in terms of like medical. knowledge behind [00:11:00] things and the science behind things.
So we'd be very quick to dismiss and say, oh, this is not something, you know, let me focus you back on this. So we try to redirect them, which is not entirely wrong. But sometimes, you know, might be a little dismissive of what they're experiencing or what is of importance to them at that moment. So, so also it gave me perspective to just stop.
And not be dismissive, and just listen and hear them out, that is the prime thing going on in their life. Let them talk about it and then get to what is important from my perspective as their physician for their health. That was the second thing. Um. And the third thing it, it helped me learn was patience.
Lots and lots of patients, you know, not to get flustered if a patient asks me a question or sort of challenges my authority in those things, then to maybe step back and say they're advocating for their health, even if it's Miss knowledge or not the right thing that they're bringing up, but they took the time to read up [00:12:00] and they took the time to ask those questions.
So number one, I applaud them when they do that, instead of getting all dismissive and, Oh, stop being Dr. Google and this and that. I'm like, no, ask me these questions. I want to hear them out. I want to then teach you back the science behind it and what I think about it. So lots of patients like that, um, so those are the three things I think that sort of changed me as a physician.
Arti: I think those are all wonderful things and qualities that patients are hungry for. Many patients in endocrinology clinics are feeling dismissed. And I would love for you to kind of give us your insight as to why you think that's happening. And perhaps what we, as thyroid specialists, could be doing differently to prevent that gap between us and our patients.
Ruchi: Yes, so I think the first thing that comes to mind when I hear that question is that, you know, often the [00:13:00] symptoms due to thyroid disease are non specific. And, uh, they really vary per individual and also, you know, based off the severity of the disease. And so when the patients come in and we focus on the blood work, I think they feel very dismissed.
Like, I think what we need to do is to take time to hear their symptoms and what's really going on with them. Uh, because even when we tell them, you know, your thyroid labs are absolutely normal, they are feeling miserable. That's the first, that's the whole point that they're there to see you. And so just taking that time to hear out what's going on with them and even maybe suggesting like some other, um, causes of their symptoms, going through them one by one, suggesting, have you screened for this X, Y, Z?
You know, I think that just guiding them, not dismissing them. I think that'll help build back that connection. So that's a big part of the disconnect because they feel like we don't understand. We don't get it what they're going through. And we're so focused on like one set of labs that we [00:14:00] see, which are normal or might not be normal.
So I think. that lack of like, you know, that connection that we build initially because we're so focused on getting them, just telling them, okay, labs look good or symptoms are not due to thyroid or due to thyroid and start this. So it's also not like one treatment fits everybody, right? So we might have to consider to add another kind of therapy on top of what they are.
And, and even setting that expectation, pre expectation that not all symptoms would get resolved, you know, we're not going to be able to help fix them completely with thyroid hormone replacement. So just that too, I think, is a, is a big step towards making that connection with the patient.
Arti: Absolutely. And hypothyroidism symptoms are vast and also oftentimes multifactorial and compounded by other factors.
And so thyroid hormone is not a magic pill. And I think that [00:15:00] Patients need to be counseled to manage their expectations on what their symptomatic changes and also counseled on other things that will augment improvement of their symptoms. I think we have maybe been taught through training or perhaps it's also the fast paced nature of most office visits for endocrinology now.
Um, We've been taught that hypothyroidism is like this basic, easy thing that you just fix with thyroid hormone, but truly it's not. It has perhaps always been or perhaps has become something much more complex. We have different therapeutic options. Patients are getting different information. And I think it's a real opportunity for us to give our patients guidance on not just [00:16:00] thyroid hormone, but on how we can get them to feel better because ultimately, we as physicians are tasked with providing care for a human being.
We're not here to fix your TSH like that. I think some physicians or the way people, the way time is allotted for patients in traditional clinics nowadays, it's like, oh, this is a hypothyroidism patient. When I go in there, my goal is only to prescribe the right dose of thyroid hormones, so I can borrow time from them to give to my more complicated patient.
And clearly, it isn't working. And so, I think, um, I think establishing expectations and also supporting our patients and validating their [00:17:00] symptoms is so important. And once we do that and we have some trust in, in them, that's when we can start sort of giving our expertise. to them. But if we have a patient with a wall up, then it's too soon.
It's too soon. Um, so tell us, Ruchi, tell us a little bit about hypothyroidism. What is it?
Ruchi: So to understand hypothyroidism, I'll tell a little bit about the thyroid gland. So the thyroid gland is a small butterfly shaped organ or a gland sitting right in the lower part of the neck. And it makes the thyroid hormone, which is considered a hormone for energy.
for metabolism, and so when the gland decides to become underactive and is not making adequate thyroid hormone for the body That's when we call it hypothyroidism. And so imagine that, you know, the metabolism is tanked down. So the patients will get a lot of different symptoms, [00:18:00] like being very tired, sluggish.
They'll start to gain weight. Uh, they might feel cold when it's not necessarily cold outside. Um, and remember, metabolism at All levels is affected. So dry hair, you know, dry skin, brittle nails. Women might get irregular periods. So metabolism getting affected at every little level that it can. So that's hypothyroidism.
Arti: And what, what testing do you recommend using for hypothyroidism diagnosis and also, um, following the treatment plan to see if it's working?
Ruchi: Right, the diagnosis of hypothyroidism has to be like a combination or a blend of like clinical evaluation, but also diagnostic tests. So those are very important.
And the ones that, you know, help us Decide that really something is going on. Um, it's based off a hormone that another gland, which sits right under your brain, it's [00:19:00] called the pituitary gland, so it makes something called the TSH of the thyroid stimulating hormone, which then goes and stimulates the thyroid gland in the neck to make your thyroid hormone, which we measure in blood work as T4 or T3.
So really the TSH and the T3 and the T4 levels, those are the three, I think, Um, key diagnostic tests, blood tests that help diagnose, uh, hypothyroidism.
Arti: There's a lot of debate in patients and what they've heard from internet sources or non endocrinologist providers on the value of TSH. And there are several people who say that TSH does not necessarily have to be out of TSH by itself cannot diagnose hypothyroidism.
What is, what are your thoughts about that?
Ruchi: So I completely agree. Lots of like complex thyroid panels that are out [00:20:00] there that different labs offer to the patients. And, uh, several of the testing, not just TSH, but they have a whole list of things that they want to get checked. Uh, but what, but how I approach that is I, I tell them that these tests are relevant.
Um, but in some specific and very, like, specific situations, like, you know, pregnancy or if you have kidney disease or end stage renal kidney disease and stuff like that, but really to diagnose hypothyroidism, um, those three labs should make sense. If there's something really going on, blood is going to catch that, like, we're going to catch that on your blood work.
Um, so I really stress on that. Then I explain to them about the pituitary and the thyroid and how the feedback mechanism works. Because once they hear that, once they understand the loop mechanism, it starts to make sense that, you know, if something's going on, we are going to see something abnormal on the blood work.
So that's how I sort of start. I give them a little bit of background and then lead into like what's the [00:21:00] actual relevance of the test. And for most part that works, I think.
Arti: Yeah, and so how I like to think about it is there's this gland in your skull right underneath your brain called the pituitary gland.
It's the boss gland of your body. And I like to say it's small and mighty, kind of like me. And it, it tells all the other glands in the body what to do, including the thyroid hormone, including the thyroid gland, which is a beautiful butterfly shaped gland in your neck. And when the Thyroid isn't working and it's not making enough thyroid hormone, the pituitary starts to yell at it using a hormone called TSH, Thyroid Stimulating Hormone.
It is exactly what its name says. It is there to stimulate the thyroid to produce T4, which, and T3, or T3 that gets peripherally converted. [00:22:00] From T4 to supply with the body with their adequate metabolic needs and so that's why we are We rely heavily on a hormone that's not necessarily a direct thyroid hormone, um, but a brain hormone to guide us in the diagnosis of hypothyroidism.
And the reason that we rely on TSH heavily is because it is a great lab assay. It has nothing to do with what we care about, right? Because I think some patients think that Well, my doctor isn't ordering, you know, a reverse T3 and all of these other things because they don't care about those, those aspects of my health.
That is actually not true. If we had another test that would be as helpful, [00:23:00] of course we would order it, you know, so long as it wouldn't cause the patient financial toxicity or something like that, but of course we would order it. Um, but. A lot of times, there are people ordering a multitude of thyroid labs or calling it a full thyroid panel, which, by the way, is a not, is not a thing.
There's no, like, such test as full thyroid panel. There's, like, different order sets that somebody might have named full thyroid panel in their own EMR, but, like, in clinical training. There's no such thing as a full thyroid panel. So I get irked by that sort of that term. But, but, but, but I think it's important for patients to know that it isn't a lack of thoroughness.
In fact, it is a deep understanding of the limitations of The tests that we ordered, the tests aren't [00:24:00] perfect. And so, um, as endocrinologists, we really need to identify what tests will provide useful information more than confusing information for our patients. You mentioned T4 and T3. Which free, which T4 and T3 tests do you like to order?
Ruchi: Yeah. So I think, uh, we have a free assay, like for free T4, T3, as well as the total. I like to do the free for the T four, uh, because, you know, the, the thyroid hormone in the body is bound a lot of different proteins. So that's when we measure a total T four or T three, we are measuring the one that's bound to the protein as well.
And so sometimes if the protein levels are up or down for any reason, then the total values could be reflected differently or not accurately. And so the free, free assays are definitely better. Uh, but in the T three world, you know, and now assays have changed as time is. Advanced, but, but previously the free T3 assay was not very reliable.
So we'd often for T3 specifically go to a total. Uh, [00:25:00] but that's changed with newer assays that we have developed, uh, new generation 3D3, 3D4 are perfectly fine to check and in fact, most reliable, um, in compared to like a total D4
Arti: or D3. I think that's actually really helpful. Because I don't think many endocrinologists know that the assays have been updated.
We have a lot of literature saying that the free T3 assay is unreliable. And what that means, from a clinical perspective, is that they have looked in studies and found that, um, in more accurate assays that aren't commercially available, the commercial test is not the same result as the more, Um, accurate research based test.
And so a lot of endocrinologists will say, Well, the free T3 assay isn't accurate, therefore it's not helpful. But you're saying that that has been updated. Tell us a little bit [00:26:00] about that. When did that change? And, um, when did you start adding that to your? Your panel.
Ruchi: So I think it's been updated for a while now, at least last two years or so.
So as fellows in training, I had been taught about, you know, always order a total T three compared to free T three. And maybe I still do that out of habit, but, but really, um, I make it a point to add a free T three to the panel that I'm checking to, and for most part, it correlates with how I would've interpreted a total, like they're in sync.
And so maybe for the last two years, started to use free T three more. Um, I don't know exactly when the SS switch happened, we'll have to go back and check that. But, uh, but I think it's absolutely safe and reliable to use a free T3 compared to total T3 in this new modern world.
Arti: Yeah, and I think that will actually help patients feel better about it too because they want More testing and most of these tests are not expensive at all.
I know the cash price for TSH in our clinic [00:27:00] is less than 10. And, um, I think similar for free T4 and free T3. So, you know, there are some clinics that kind of price gouge on labs, but they don't have to be very expensive, which I think is another important part of the puzzle. We don't want to be ordering unnecessary labs that could.
Cause financial toxicity to our patients unnecessarily. So now we have, we sort of do have a thyroid panel that we can be offering to patients to help them feel maybe more comfortable with the thoroughness of the evaluation of their thyroid. Do you ever have a scenario where TSH is normal, but your free T4 or free T3 is low or abnormal?
Ruchi: Yes, I run into that fairly frequently because, you know, in my clinic I see all of them are thyroid patients, so I run into that particular problem very frequently. Now when that [00:28:00] happens, um, my first to go instinct is that it's an assay issue. And so I always like to recheck with just a different assay at a different lab.
And for most part, my problem will be solved right there. Like, I'll get the answer to my mystery. Uh, but sometimes certain rare, uh, not very common thyroid disorders can present with labs that don't exactly make sense right away. So then you have to start to think about zebras. Uh, but like I said, common things being common.
Assay issues and especially now that, you know, people use so many hair and skin supplements, like, um, the biotin factor plays in. I don't know how many patients out there are aware of that, but biotin is in a big dose in most of these specific, like, hair supplements, and it can interfere in, uh, in how the thyroid hormone levels are measured, and spuriously make it look high or low, depending on whichever assay.
And so, artifact, like I said, with biotin interfering versus an assay issue is the most common thing that happens when I see [00:29:00] labs that don't make sense. But then I also, as step two, go to like zebras to make sure I haven't missed anything.
Arti: Mm hmm. And tell us what some of those zebras might be.
Ruchi: So the zebras could be like, remember the gland that we spoke about, the master gland, the boss gland in the body.
If there's a little teeny tiny tumor, uh, sitting there and producing excessive TSH, then we can have lapsed lucas that don't make sense, uh, versus there's something called like thyroid hormone resistance. So the body has adequate thyroid hormone but just not able to act on the right receptors. There's resistance to it, um, and some very rare things like you know, with certain cancers, certain ovarian cancers, etc, which are very very rare to encounter, but that can happen too.
Arti: You're, you're, um, making me remember all my step one struma ovarii, uh, memorization. Um, but, so let's talk about thyroid hormone resistance for a minute because I [00:30:00] think, is it common? It's very rare. It's very rare to
Ruchi: have it. Like I said, it's a zebra, zebra, unicorn. Have you ever seen it in your clinic? I have maybe like two patients in my 10, 11 years of career where I've actually diagnosed thyroid hormone resistance.
Arti: So I think this is important because online, this concept of thyroid hormone resistance is made to seem like it's all over the place. Like so many people have it and it's being misdiagnosed and underdiagnosed. And actually, Ruchi is the first endocrinologist I've met who's actually seen patients. with thyroid hormone resistance.
And it's one of those things that we learn about in training and for our boards. And most of us are not working in thyroid specific centers of excellence in big cities like Houston. And so most of us don't have the volume of exposure to thyroid disease and rare thyroid disease. [00:31:00] Ruchi's a referral center for complex patients for All of Houston, as well as probably many other patients in Texas and Louisiana, probably.
And so she sees so many thyroid patients day in, day out for years and years and years. And she has seen Two patients with thyroid hormone resistance in her career, which I think I think by now we can assess that Ruchi is a very thorough, compassionate, patient centered physician who isn't like missing a ton of diagnosis of thyroid hormone resistance.
If if you're concerned that you have thyroid hormone resistance or if I get concerned that I have thyroid hormone. resistance, I'm going to go to her because she is the expert. And so I think that that's an important thing for people to understand that if such a specific thyroid center is seeing it rarely, it's truly rare.
And as [00:32:00] far as, um, um, uh, thyroid hormone secreting tumors, TSH omas are what we call them. I remember we had one when I was a fellow. And everyone was all excited in the department. I mean, poor patient, but everybody was like, Oh, my gosh, look at this case. We were all talking about it all excited about it because these things are exceedingly rare.
And so I think that It's not that we're not thinking about them. They're always in the back of our head. In fact, we would probably be in an odd sort of way kind of excited to see these rare diseases. We would love to discuss them, do a case report on them, um, and have that experience. So, um, it's not that we're trying to under diagnose thyroid disease.
It's something that we are excited about and that we know how to treat. And, you know, It would, it's actually kind of a breath of fresh air sometimes when we're like, okay, this, this patient does have thyroid. [00:33:00] This is something I, I know how to, I know how to handle. Um, I, I think that, uh, that was very helpful.
So thank you for, for walking us through that. Um, tell us about reverse T3. Is it something that we should be checking? Is it something that is helpful? Is, uh, Yeah, just tell us your thoughts on it.
Ruchi: So what I tell my patients are, you know, the reverse T3 is definitely a valid test, useful in very specific situations, not your run of the mill diagnosing hypothyroidism.
Like maybe in a, I don't know, in a pregnant patient or a sick patient, we can consider to do that. But again, it would be more to help diagnose some other thyroid conditions, not necessarily like hypothyroidism. And, and I don't dwell too much into it after that because, you know, it's a whole can of worms that you open up if you start to talk about it.
So I leave it at that. I give them a little bit of my spiel about how it's not relevant to them right [00:34:00] now. And if it was, I'd be very, like you said, very happy to check it because it'll help me get to my diagnosis sooner and get the patient feeling better sooner. Um, but that's how I approach it. I keep it short and crisp when I describe the test to the patients.
Um, and I tell them I will order it if I think it will add any value to their management.
Arti: There's this concept that if the reverse T3 is high, it competitively inhibits the, the T3 receptor and causes patients. to not have, even if their T3 is normal, it causes that T3 not to work as well. Basically, there's this theory that, that reverse T3 competitively inhibits the T3 receptor.
However, in reality, The T3 has an extremely high affinity for the receptor, and it has more affinity than reverse [00:35:00] T3. So, if you've ever taken chemistry or organic chemistry, you know that if you have a scenario where there are two Molecules that have very varied affinity for a receptor. The one with more affinity is going to bind every single time, and especially if that affinity is much higher.
So the theory that reverse T three is going to compete with T three doesn't hold much water because. It just chemically can't do that, and so I think that perhaps when people are, are telling patients that that could be what's going on, they perhaps don't have a strong understanding of, of that chemistry that is going on physiologically.
Um, Ruchi, you talked about something very, um, [00:36:00] nuanced, I think, in our recent TXCA. conference, and that was tissue specific uptake of T3. And I think that's very important for endocrinologists to understand, as well as our patients to understand. Maybe the TSH isn't telling us all of the information, and certainly, The symptoms that the patients are describing are true.
I don't think there's any question about that, but perhaps we can alternate the way we think about therapies for hypothyroidism or use non straight T4 formulations like levothyroxine and synthroid to address some symptoms due to hypothyroidism. due to that peripheral uptake of T3.
Ruchi: That is so true because, you know, when we place our patients on like just Levothyroxine, which is the T4 kind of thyroid hormone, [00:37:00] not all patients feel better.
Yes, we fix majority of them, but around 10 to 15 percent are still facing those symptoms, still having that decreased quality of life. I think that's when especially we should pause. And think about the different, like, how in the, in the brain, you know, we have the hypothalamus or the pituitary, how the T3 is being utilized in the brain versus how it's being utilized in the peripheral organs, your tissues, your muscles, your other organs, um, and there is a discrepancy because not all symptoms have been resolved just by giving the T4.
The T4 is something that guidelines, you know, advocate for because number one, it's very easy to sort of, Um, help manage, like how to adjust doses, because it's very straightforward in, in that regards, TSH, you check a TSH, you adjust dose accordingly. So quite straightforward. Physicians find it easy. So guidelines said, okay, this is an easy way to fix somebody.
Let's go for it. But really, we haven't considered that T4 is getting converted to T3 in [00:38:00] the body, which is actually the active hormones. And again, it's action in the brain and the different peripheral tissues is going to be different. So, when the patients do not feel better, the labs look perfect and beautiful, but they're not feeling their best, despite being on the right dose.
Then we have to Take a step back and think maybe we need to add some alternate therapy or another kind of hormone which is the T3 hormone to their regimen. And, and most of us as endocrinologists have been taught during training to shy away from that because we want to practice like evidence based medicine and the guidelines recommend T4 to be first line.
But really not anymore because there's so much literature out there that you know patients can feel better once you add that T3 on T4. That's not applicable to all patients. This is a little subset of patients and it's not little, because hypothyroidism affects millions of patients, so 10 percent of that is a huge number that we're targeting.
And so these patients will benefit from adding T3 on top of T4. [00:39:00] Um, so that's where I stop and think about the different uptake, how T3, T4 hormones, I sort of go over the cycle with the patients, and then tell them, perhaps it's time to add that T3. And I keep a very low threshold, and that's, With experience with like the latest literature coming out, so you have to stay abreast of that and keep an open mind and I've started to incorporate that T3 with the T4 when my patients tell me they're not feeling their best just on T4.
Arti: Yeah, I do that too. And I think it works very effectively for for many patients. And I think that's another situation like we talked about before of hearing the patients. Story their symptoms and coming up with solutions and sometimes the solution is t3. Sometimes the solution is getting better sleep Sometimes the solution is going for a walk every day.
You know, there are a multitude of solutions for various symptoms and as long as the doctor keeps an open mind and the the patient Trust [00:40:00] the doctor. Um, we can, we can make a lot of progress in that way. You talked about T3 and T3 I think can be a very good medication, but it does have potential risks. So I think it takes a sophisticated physician who understands the risks and benefits of T3 and uses it responsibly.
So, can you tell us a little bit more about T3? What does it do? Is it a very potent medication or is it something that we can give in big doses? What are your thoughts on that?
Ruchi: So the T3 hormone replacement, so that's the active hormone in the body, right? And then assuming that most of the T3 in the body is being by conversion of the T4 to T3.
So really when we start to prescribe that we have to be very careful because it has a short half life. It's very potent It's the active metabolite [00:41:00] So it's going to act on tissues which really matter like the heart Right away and can cause trouble if it's not dosed correctly. And so we have a lot of different alternate practitioners out there, you know who will incorporate that theory is right, but they're not doing it correct practically, I think.
So they're thinking for the benefit of the patient and the theory wise they're thinking about it correctly. But like you'd mentioned a couple a couple minutes ago, they do not have the deep understanding of how these hormones work. And so that's why sometimes when they start to dose patients, um, the dosing has to be very appropriate in what ratios the T4 and the T3 have to be combined.
Uh, the, I don't know if I can segue into that, but you know, there's certain natural thyroid, uh, supplements that are marketed, uh, out there, which have a combination of the T3, T4 already set for us. Which is absolutely not physiologic, like the body wouldn't do it like that. And so, but they're marketed as being natural, uh, because they're usually coming from like [00:42:00] a pig or a horse's gland.
And so, thyroid gland, and so they're sort of getting the thyroid hormone out of those glands. And so sort of considered natural or organic. Whereas when we're considering the T4 replacement, that's in a pharmaceutical company, it's more synthetic. So you know how even myself, when I'm researching for a supplement or a medicine or anything, any product that I use on myself, the organic or natural always catches attention.
And so we, so that's just human tendency to move towards something that will not harm your body. You know, we all want to be natural and organic. Um, but I think it misleads patients because the way they combine these hormones is not physiologic at all, the ratios. And so often I'll tell my patients, I'm more than happy to add the T3 to your regimen, but I will do it separately in a dose that would make sense that a normal thyroid gland would have produced for you.
Yeah. So that really works.
Arti: I, I agree. And I think one way I think about it, and I share this with my patients, is these [00:43:00] natural desiccated thyroid extracts, NP thyroid, um, armor thyroid, they are natural. for a pig, but we're not in veterinary medicine here. We're taking care of human beings. And as you may guess, you are not the same as a pig and neither am I.
And so we need to tailor a therapy that is matching the physiology that you should be experiencing, not our farm friends. And so I think that the idea of natural and organic. It appeals to all of us, absolutely, but there are many things in nature that are dangerous for us, including some of our illicit drugs, you know, things that you poison ivy, those are all natural.
But are they safe for us? Absolutely not. So I think that we need to take a step back and recognize that natural could be good, but natural also could be dangerous. Just like synthetic could be good and synthetic could [00:44:00] also be dangerous. It's making a tailored plan for that individual patient in front of us.
And I also like to say, I would like to dose your thyroid hormone in a more sophisticated way. And that is assessing your need for T4 and T3 and giving you those in a A sophisticated, closely assessed way that is perfect for for your body instead of throwing a desiccated product at you that You know, the problem, one big problem with those desiccated products is that they have recalls all the time and they are notorious for having, um, inconsistent dosing because they're dry pig thyroid.
That's, that's what it is. So not pig A might not be pig B, you know? And so I think that. They can be used safely. I'm not [00:45:00] completely writing them off or taking them off the table. There has been at least one study showing that they can be used safely with, um, proper monitoring and so You know, if if a patient has been on it for years doing great, okay, that's that's something that we can discuss, but I think for the majority of patients walking into our endocrinology clinics who are really looking for individualized, sophisticated, expert level care, we should be maybe offering these hormones in a more nuanced way.
Ruchi: I was just gonna add, I also have patients who've been on, like, Armor or N Petroid, these desiccated thyroid hormones, and doing great, because they are very good with follow up, you know, they are just doses as the physicians advise. So, nothing against them. If it's, if it's working, that's what we want for it to happen for you, you know, we want you to work, we want it to work for you.
But, uh, but mostly It'll cause higher or low levels and cause trouble. So you have to be very careful.
Arti: [00:46:00] Yeah, and the last thing patients need or want is to have fluctuating thyroid hormone levels due to an inconsistent medication product when we have alternative options for them that could work better and give them more stability and less lability of their thyroid disease.
You sort of touched on alternative practitioners. And potential misinformation, I would love to kind of talk about that and not in a way to necessarily throw complete shade at alternative practices as a whole, because I do think our health care system is is broken. Patients aren't. There's a shortage of endocrinologists.
It's hard to get in with us. It's hard to get an endocrinologist that can spend a lot of time with you, support you between visits, all of those things that many of our patients need. So I understand and it's never the [00:47:00] patient's fault that they're seeking alternative models of care that give them the support that they need and also some alternative practitioners provide more education on lifestyle or nutrition, um, things that really can help people feel better.
They're able to do that in, in cash based settings and things like that, that are outside of insurance more easily than. than your traditional endocrinologist in, um, an insurance based system oftentimes. So I get it. I get patients are looking for solutions. What are some things, though, that you have seen?
And also, what is the danger of treating hypothyroidism that isn't actually present in
Ruchi: So the alternate practitioners, you know, they will, uh, [00:48:00] advertise for themselves to be practicing functional medicine. And I'm not at all saying that they are the bad guys. Absolutely not. Right. Because, um, Functional medicine or alternate practitioners, the approach like you were just mentioning, it has lots of, lots of different strengths.
Like they're looking at more like preventative things that they can do, looking at the patient very holistically. It's very patient centered, which is awesome. And often will involve like nutrition, lifestyle, and other changes, which is great for the patient because they're, um, going to have like a, um, their whole mental as well as physical health will feel better.
But, but sometimes, you know, the functional medicine can have a little bit of a polarizing approach, I feel. Uh, because it depends on what context it's being used in and who's using it, right? So, unfortunately, these practitioners, how they practice or what advice they give to the patients is not very standardized.
It's not very uniform. It widely varies, depending on what kind of training they've had or how many years they've spent in training. So, number one, you can't hold them [00:49:00] accountable to it because there's nothing standardized, I feel. Um, secondly, I feel like there's a lot of dependency on supplements. They tend to overemphasize supplement use, which again, if used judiciously, fantastic.
But like you said, not all natural or organic things or supplements are always going to be good for you. They come with their own set of risks and toxicities, which you have to be aware of. And then sometimes it's expensive. They're not insurance based and sometimes they have to pay cash for it, which is okay.
Sometimes you want that and it's good for you, but sometimes you don't and you're basically getting delayed to get to see a physician who could handle that problem much better than how it was handled before. And so it's beneficial when used correctly and done correctly but can be really really harmful if done inappropriately and harmful by the meaning if you do not have hypothyroidism and you get put on these hormones, remember they are metabolic hormones, they affect metabolism at All different [00:50:00] levels.
And so the top organs that I think can get affected are the heart and the bones, you know, so the heart can go into irregular rhythms, you can go into atrial fibrillation, the heart's beating really fast and irregularly, or the bones are now starting to lose, like they have, starting to lose their calcium and minerals way faster than, than a normal person, and you're much prone to developing osteoporosis or fractures.
Uh, not just that, mental health wise, you can, anxiety, you would be surprised how many nuanced anxiety, uh, people are on these supplements, do not have thyroid disorders, you'll be astounded by the number. It's very frequent in my clinic to see these patients. They cannot sit, they're fidgety, they're moving, newly diagnosed anxiety disorders.
And guess what? They're on a supplement. with thyroid hormone in it, you know. So it has definite and I think I saw a study, uh, maybe when I was with one of my trainees like a couple months ago, where if I'm remembering correctly, all like mortality goes up if you're treated when you're not supposed to be [00:51:00] treated.
So there was some study about that too. So really looking at a lot of different risks, uh, when you get treated, when you don't have to be, or, or excessive dosing of thyroid hormones, which can happen as well.
Arti: Absolutely. And, um, Ruchi mentioned the cardiovascular complications that can occur with over treatment with thyroid hormone in either patients who don't have hypothyroidism at all or are treated to a point where they become actually hyperthyroid, where they have too much thyroid hormone.
But to put that in perspective, so what is atrial fibrillation? It is a heart arrhythmia. I think that's clear, but it can also cause things like strokes. That's, that's the reason that we don't want people to stay in an abnormal rhythm like atrial fibrillation is it can cause things that can be fatal. Um, the blood pools in the [00:52:00] heart because the part isn't beating properly and then, um, it can clot and then you can, you can throw that clot and it can land up in your brain.
And, um, these are things that actually happen. Of course, endocrinologists are biased, um, as far as functional medicine because we see the disasters, right? You know, the, maybe. 90 percent of the patients do fantastic, but when they don't, they come into our clinics and they're profoundly hyperthyroid, they have bone loss, they have osteoporosis, um, they've had a stroke, they've had it.
severe anxiety due to the treatments. I have that in air quotes, um, that that these practitioners provided for them. And I don't think they're malicious. I don't think they're trying to harm the patients, but perhaps they have some miseducation [00:53:00] or are uninformed about the potential toxicities of these medications.
And I think another thing that's very important to talk about is, Ruchi had mentioned the potency of T3, um, and I believe the Mayo Clinic did a study where they studied adrenal supplements that have been pushed on patients with this condition, adrenal fatigue, which isn't really Is not a recognized condition by any, uh, credible endocrine society in, in the world, um, because this is kind of off topic, so I won't go into detail about it, but physiologically, it does not make sense.
That's not how the body works. So it, it, it doesn't exist. But, um, but people are diagnosed with this with the sole Purpose of prescribing them a supplement to fix a problem that doesn't exist to make money off of that supplement and [00:54:00] Supplements can be toxic, but the Mayo Clinic found that the majority of these supplements that they studied under in their lab under mass spectrometry Um, they contain T3.
So people diagnosed with not even a thyroid condition, an adrenal condition, were being given T3 and T3 actually has antidepressive effects. It is a kind of last line therapy for refractory depression that psychiatrists use because it, yes, it has. Potential risk, but if there's nothing else that's helping the depression and the patient is really suffering, they might add T3 for the antidepressive effects, regardless of the thyroid status.
So you can imagine that a person is being diagnosed with adrenal fatigue being. Treated with a supplement that contains T3 feeling better because probably everyone will feel [00:55:00] better if they get a little bit of T3 and then they think, gosh, I, this diagnosis was missed for so many years and now I'm being treated with this magical supplement when really they had untreated depression that we have multiple safer therapies for, um, that can be medical or um, That can be pharmacologic or non pharmacologic or both and so I think it's sort of this trap of Misinformation, misguided information and Solutions that also a lot of adrenal supplements contain steroids.
Everybody feels great on steroids. I took steroids once I felt awesome I felt like superwoman. I ran 10 miles an hour on the treadmill that day like I felt Awesome. Until I didn't, you know, and so steroids have a lot of, um, potential side effects and complications. So I think that just because something [00:56:00] makes you feel better in the moment, too, doesn't necessarily mean it's safe.
Um, I think we know that with alcohol. Drugs, cigarettes, all of those things, they make you feel good in the short term, but they're not necessarily good for you. Um, and the other thing that Ruchi mentioned was thyroid supplements. Well, a lot of these thyroid supplements have a whopping doses of iodine in them.
So tell us what that does to the thyroid.
Ruchi: So iodine is sort of to think about it like food for the thyroid gland. So all the different hormone production that happens, it has to use iodine for it. But we're giving it an overload of iodine. Initially, it's going to use all that iodine to make too much of the thyroid hormone.
But then if you have some underlying something going on, then it'll sort of go into that phase of where it's not producing it anymore. So you can have hyperthyroidism, but you could also end up with hypothyroidism. So iodine supplements you have to be super duper careful with.
Arti: [00:57:00] Yes. And we have some fancy words, um, in endocrinology for, for those effects, um, that, that your endocrinologist can talk to you about.
But I think that the thyroid is extremely nuanced and there are ways to treat hypothyroidism safely and there are ways to use a more whole person approach to thyroid care than what we have been doing in endocrinology. And I think that the fact that we have been slow on the uptake of really treating thyroid disease, whether it's real or that's what the patient is thinking that they have and that's why they're coming in.
Um, And perhaps making patients feel dismissed and in some of our [00:58:00] clinics that are in a, in a really fast pace at the same time, social media has blossomed. Um, so there's a lot of. information availability, some of that great, some of that not so great, and some of that very mixed, I think it's sort of created this perfect environment for patients to be tremendously confused about thyroid care and to go down a rabbit hole that could potentially be dangerous for, for them.
So, um, many of our listeners are endocrinologists or clinicians that might be taking care of. patients living with thyroid disease. As we close, I would love for you to just talk a little bit more about some steps that we can take to ensure that we protect our patients. Because as an endocrinologist, while I feel frustrated by people who are spreading misinformation, I [00:59:00] absolutely do.
I also believe it is our privilege and obligation to provide patients with information that they can digest and understand and feel comfortable with. And I feel that we have not done a good job of that in our field, sadly. And this isn't to point fingers, I know. I know our colleagues are working extremely hard, but yet we have to face the reality that we have lost our patients and to our detriment, but mostly their detriment.
And the point of this is to bridge that gap between endocrinologists and, and our patients. And I think we really need to look critically. At where we failed, you know, looking at where we failed is how we innovate and how we become better. And I know you have, I know you have done [01:00:00] that. And so I would love kind of for you to, to talk about that as we get near closing.
Ruchi: Absolutely. So my approach to that or how I think about it is number one, first step is connection to the patient. And how do we go about that? It has to be a lot of empathy. a lot of listening. Anyway, I mean, a lot of buzzwords like mindful listening or thoughtful listening, but pretty much just listening, you know, taking the time to really listen to them.
So I think with empathy, listening to them, giving them that safe space where they can actually tell you how they're feeling and not feel judged or dismissed. I think that leads to connection. Which is step number one. Once you've connected to the patient, step number two is education. Then you go into educating them.
The trust has been built. You tell them about the science, how it works, risks and benefits. We might not have all answers. So guiding them to the right resources, like if they have depression. I've had [01:01:00] several patients that I have referred to the psychiatry or psychology to help them with depression, and now they're feeling a zillion times better.
But I took that extra five minutes to tell them you need to see a therapist. Come back and tell me in three months that you've seen somebody and are feeling better. So I have to push them sometimes. Like if they have anemia, for example, which can cause similar symptoms, or sleep apnea, like guiding them.
Go see a sleep doctor. I think it'll be awesome to place a referral for a hematologist who can help you with anemia. Things like that. So education and not trying to fix all their problems at one go. Trying to get the resources, you know, branching it out. We have colleagues to help us out. So maybe doing that.
So education, step number two. And then third, really advocating for them. If they run into, you know, referrals from subspecialists to subspecialists, I often will tell them, go see your PCP. They are going to consolidate all that care for you. And so, after that, I think, Advocation. And final step is maybe, Collaborating with them on a plan.
On a goal. [01:02:00] Okay, we're going to work on this. And that's our plan together. So like strategy, which is collaborative so that, you know, the field, you know, there's this word like shared decision making, so maybe that, you know, just sharing that decision making with them, they feel on board, it's their health, they feel in charge and empowered.
I think that really helps. So those are the four things I do in my approach to these patients.
Arti: Absolutely. And I think that, um, we have gotten to this breaking point where the relationship is adversarial and in some, in some settings, and the patient has an expectation that they're not going to be heard.
And the doctor has an expectation that the patient is not listening. And it should be sort of opposite, like the doctor should be there to listen, first of all. And second of all, an adversarial relationship between a physician and a patient is not going to [01:03:00] be a successful one. Um, and so I think really collaborating and one thing I ask my patients on every single visit, you can ask my patients if I ask them this is, does that sound reasonable to you?
Does that plan sound reasonable to you? And. Most of the time they'll say, sure, yes, because we've made the decisions collaboratively, but if not, that they have the opportunity to say, hey, well, actually, I really, I like this part of it, but this part of it doesn't seem like something I can, um, manage at this time, or I might try that in the future, or that's just not something that I want to do.
So let's do this part of the plan. And once you have agreement with them, then you have a whole new relationship with the patient and also like they're engaged. They're like, yeah, I'm on board. I'm gonna do this and we're gonna try it and then and the follow up support. It's like, I think, you know, it's so [01:04:00] difficult now to get into endocrinology that sometimes some endocrinologists only get to see their patient once a year and patients who need support or who are confused or don't feel totally comfortable.
the plan or they're not doing fantastic and most endocrinology patients are not like, you know, it's not like we're treating strep throat with an antibiotic and they're fine to, to go off on their own. These are chronic metabolic conditions that 99. 9 percent of our patients have. And so I think that that follow up is so, so important.
That recognition that. You're on a team together, not just today between the four walls of this clinic, but long term, if this doesn't work, I'm here for you to figure it out. Ruchi, can I ask you, how much time do you have, um, in your clinic with your patients?
Ruchi: So that's a tricky question because it varies, um, for new and for followups, but for majority, I think I'm trying to think, I recently changed my [01:05:00] template.
I think it's a, it's a 30 minute slot,
Arti: but you
Ruchi: actually do not end up. Getting like those 30 minutes, myopatient, it's a different time gain. Um, in short, what I'm trying to say is, it doesn't matter how much time is allotted. What I do is, you can connect within 5 minutes. So simple things like, because it's, we can't be, we can't get more time.
Like that's how the structure of the healthcare in the United States is right now, right? So we're not trying to solve like the bigger, like the bigger world problems. But what I do is I pull up my chair and I sit right in front of the patient. I sit down and I face them and I make eye contact and sit down and ask them how they're doing.
What's going on with them? Like what can I help them with? Just that little things, and I'm sure a lot of other of my colleagues had even fantastic and better ideas on what I'm doing, but making that connection, even if you had five minutes and you're running late, like, once they see that you actually, like, sat down with them, and interacted with them like that, I think it makes a [01:06:00] difference.
Um, that's what I have felt, like, it doesn't matter you got 15 minutes or 30 minutes, yes, in certain, um, endocrine disorders like diabetes, where you have to do, like, extensive like life like counseling and how to use their cgms and other things yes you need time but with thyroid I feel like that connection, once you have that, and that trust, the visits go faster because now they know what you're talking about and they trust you.
Arti: Yeah, and it's quality of time spent, you know, there are constraints, you know, in different practice models. The majority of the way that endocrinologists are practicing now, there are time constraints. I think that's a reality that most endocrinologists have to face. Even in a direct care clinic, we can't spend all day with one patient, and nor should we, because that's not a good use of anybody's time, theirs, nor ours, right?
It's the quality and the intent with which you listen to them and getting to [01:07:00] their level. I mean, one thing that I learned somewhere in training was to always be below your patient. And so, you know, whenever I'd be in a hospital room rounding on my patients, I would always kneel at their bedside and It just felt so human to me, and standing above them felt very, um, indicative of a top down approach, but I think, and I remember my patients would be, oh no, pull up a chair, you can sit, you can stand, that must be so uncomfortable, but I felt that that helped me connect with them and helped us even physically set up the room in a way that, you know, Patient, you are the most important person in this room.
I am kneeling at your side. And I believe that philosophically and also demonstrated that physically, and it, it, it set me up for a different type of approach to my patients. And so I think that, [01:08:00] you know, the, the setting where you're behind a computer standing up, not even facing your patient is just a setup for a disaster.
Um, and so I do think that when we can taking an approach that really makes a patient feel. connected with you physically. I mean, body language is huge, right? And so, uh, I, I think that's so helpful and so helpful for listeners who might be in a traditional setting where they need tools to help them connect when they're not in control of their, their time and their schedule.
So thank you. So helpful. Is there anything that we haven't covered that you feel like we missed or that you would like to share with our listeners? I feel
Ruchi: like, like you said, it's time we get in charge and, you know, uh, help our patients out, advocate for them and for the science and do it correctly. Um, and I think we all have to get together to do that.
[01:09:00] That's sort of my closing message, that we got this, but we got to work together.
Arti: Absolutely. And I think that as endocrinologists, we have the potential to be extremely patient centered. And I think that the healthcare system is extremely frustrating, particularly in endocrinology, um, for various different reasons.
But if we can come together, Take a step back and remember that we're here for the patients. And we collectively have that spirit of patient centeredness and lose the adversarial nature that has come out of the tragedy, tragedies of the limitations our healthcare system has put upon us, then, then we win.
And a win is not always financial. You know, in fact, it rarely is financial, right? A win is bringing joy back to our [01:10:00] patients lives, back. Into our own lives and regaining the. Authority that we are experts in the field because we do know a lot about the thyroid. Do we know, do all of us know every single detail about it?
No, but we can be constant learners. And I think patients are craving that and appreciate. Physicians who aren't, who are willing to accept that they don't, they don't know everything but are willing to learn for their particular patient. So I think if we can collectively change our outlook and attitude, we have a lot of potential good to do for our patients in our field.
Ruchi: Right. Like you said, it's an honor, but also an obligation, I think, to do, to give that impactful patient care, which we're trained to do. We have the expertise to do it. So absolutely.
Arti: Yeah, let's go get them. Awesome. Well, thank you so much, Ruchi for coming on today. This was such a wonderful conversation and I love talking with you every [01:11:00] single time Vidya is here with me and we were just talking about how your voice is going to start our day with such a soothing, um, beginning to a busy day.
So we're so happy to have gotten to spend this, this time with you and look forward to connecting very soon.
Ruchi: Absolutely. Pleasure
Arti: is
Ruchi: all mine. Take care.
Arti: Take care.
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