Patient Care and Practice Boundaries

This week in our case studies, we had a really interesting conversation. We talked about a patient who was presenting with secondary hypothyroidism, so rather than the traditional high TSH and then low T3 and T4, what we were seeing was a lower TSH, but yet still low thyroid hormones. We examined some of the reasons that can be true.

Keep reading to uncover the reasoning, but more importantly, to understand why having boundaries in place with our patients is of utmost importance.

Reasons Why It Can Be True

Lipopolysaccharides

We talked about how even things like lipopolysaccharides can cause a block between the communication of the feedback of thyroid hormone to the TSH, and so, you can see a euthyroid, or this sick thyroid type of presentation from gut-based dysbiosis. However, another reason you can see that is because of cortisol. 

Cortisol

We discussed the stress implications, particularly for this patient. As we unraveled that, what we learned about the patient (probably more the heart of her issue) was that she had a stress-based background, a lot of trauma, and many things had happened, struggles in her life. And she began to shed tears when it was brought up. But then she began to build walls. And as the practitioner began to suggest this might be really the crux of what's going on, she said, “Nope, I'm only here for thyroid, and I'm not going to think about anything that's going to help me to address the stress itself.”

In this situation, the practitioner felt very limited, feeling that we, as medical providers, can't put our best foot forward if the key thing that's going on is stress response, and the patient is unwilling to deal with that.

It begged the question-- ultimately, how do we feel about accepting somebody like this into a membership-based practice? 

Boundaries

This brought up the topic of boundaries as we asked ourselves how can we work with somebody like this. One of our collaborators suggested, “You know, a good idea would be to say, ‘We're going to do a temporary program. It's going to be stress-based. And then we're going to re-measure some of these thyroid parameters and see how much they respond to stress.’” 

We agreed that what fundamentally had to happen here is education. And, the patient has to know that in our clinical opinion, the primary issue is the stress response. It's likely creating cortisol that's causing a miscommunication between thought, the thyroid feedback and the pituitary, and without addressing that underlying issue, we can't expect that the patient will have the fullest outcome. We just need to educate and be honest with the patient. Then, the patient and physician, both together, can decide from there where they want their next moves to be in terms of how that relationship will go forward. 

These are hard topics, but they're appropriate topics. We need to decide if somebody is the right fit for us because if we feel that we're limited in giving the therapy that we need to give, that well may not be a relationship to enter into. You may have to part ways with a patient who is unwilling to take your suggested path of healing.

Conclusion

This week's conversation was a perfect example of the realization that managing patients is more than tweaking the thyroid and adding in some supportive nutrition. That is a great first start, but it's also how they enter into the relationship and where we're going to take it from there. Thankfully, we tackle these harder issues on a regular basis at Origins Incubator. This is some of the real value of our community coming together to say, “Hey, what would you all be doing?”

We will keep our discussions going and continue to share key takeaways so that we can learn and grow from one another to the benefit of our greater communities.