How do you educate a referring physician, or any colleague, without sounding judgmental? I’m not sure you can. Here’s how I tried.
How do you educate a referring physician, or any colleague for that matter, without seeming like you are questioning his or her medical knowledge or judgment? Well, maybe you are questioning it, that’s why you feel like he or she needs educating.
Case in point: I received a call today from an employee of the hospital. He tells me that his daughter is pregnant and was just told by her OB that she has hypothyroidism and she needs to see an endocrinologist right away. She is already 25 to 26 weeks pregnant so they are very concerned. To be more accurate, the daughter is very upset and very scared and has been looking on the Internet at all the bad things that can happen if she goes untreated. So I ask what the TSH is. It’s 0.3 mIU/L. I’m thinking, “Oh I must have misheard him, the OB must have said hyperthyroid.” I told him that 0.3 is normal for pregnancy, but he said they were told that this was abnormal and even lower than last time (it was apparently low normal when she was at 8 weeks gestation) and that she needs to be seen right away. I asked if maybe it was 0.03 and not 0.3. He faxed it to me. It was 0.3, and the free T4 and free T3 are normal. And while I was already dismayed at the thought that an OB did not recognize this as a normal change during pregnancy, handwritten on the bottom was “subclinical hyPOthyroidism, refer to endo” (capitals by me). I reassured the father, told him to tell his daughter that this is supposed to happen, she doesn’t need me, she doesn’t need meds (I wanted to say she needs a new OB) and I gave him the link to a Medscape article that outlines the normal ranges for pregnancy. Then I printed out the same article and mailed it to her OB.
Was that mean of me? Catty? Some other female mammal reference? Probably. But I am appalled that an OB (a) did not recognize the normal change that occurs in pregnancy and (b) doesn’t know that the TSH goes up in hypothyroidism-not down. I would understand if, say, a dermatologist (no offense to any derms out there) didn’t know that a TSH of 0.3 is perfectly normal during the second trimester, but an OB? Come on! That’s like a gastroenterologist not knowing that iron can cause black stool.
Think of the unwarranted worry on the part of the patient and her family. Fortunately, the father knows me (or at least knows of me) and was able to call and get this straightened out without prolonging their agony and without wasting health care dollars. And without depriving someone with a real issue of a new-patient appointment.
Could I have ignored her ignorance? You know, just have the conversation with the dad and be done? I suppose. But then think of all the other pregnant women being told the same thing. Worrying for nothing. Taking time off work, making doctor appointments they don’t need. Could I have picked up the phone and called her? Maybe. But I know myself, and I can’t see that conversation being pleasant.
We all make mistakes. I don’t claim to know everything there is to know about medicine. I won’t even claim to know all there is to know about endocrinology. But we should all know the basics of the field in which we practice. And when we don’t, someone needs to bring that to our attention.
What was the last experience like this one you had? What was the net-net?