The ‘Perfect’ TSH?

Have you been told somewhere by someone that the ‘perfect’ TSH is 1.5 mIU/L?  This is a wonderful, terrible & wonderfully terrible example of ‘magical numbers medicine’.  As a push-back against the published reference ranges we’re given, that are so wide you could drive a truck through them, there has been an over-correction by some, leading to the myth of ‘magic numbers’.  We can narrow the reference range substantially for many parameters with good rationale, make no mistake about that but once we start setting ‘aspirational goals’ that are explicitly rigid…well we’ve done 2 things 1) forgotten about the patient to whom this result belongs and 2) disregarded viewing each result as part of a ‘pattern’, that we must piece together and make sense of.

Back to TSH then… if my obese patient had a value of 1.5 mIU/L this in fact would be woefully inadequate.

Also too low for any patient, no matter their size, if their T4 is low and we’d like a higher value as well for risk minimisation in our elderly clients too. 

But the same result would be excessively & worringly high in my patient who’s undergone thyroidectomy. 

Being given a list of ‘magic numbers’ will never replace learning labs correctly.   When we do this, we come to truly know that meaning can only be made of the markers when you can answer the following questions:

  1. What is this (metabolite, analyte, binding agent, plasma protein etc)?
  2. What do I know about its physiological and biochemical context – what is its role and regulation in the blood, what moves it and to what magnitude?
  3. How have the reference ranges been determined for this lab – who am I comparing my patient to?
  4. Therefore, what is the significance of a result that is: ‘normal’, ‘low normal’, ‘high normal’, below or above the range?
  5. Does this value ‘fit’ with my patient?
  6. What else could explain an unexpected result?
  7. How strong is my level of evidence?
  8. What do I need to do from here to confirm or refute this?
  9. And a few more 😉

 

Realising the full value of any test result in terms of what it reveals about the person sitting in front of you, requires these skills. Unfortunately, in contrast a list of magic numbers will often lead you astray.  And building your scientific knowledge about  labs will not only help you avoid the pitfalls of pathology but will strengthen your pathophysiology prowess in surprising ways, saving your patients a packet in terms of additional extraneous testing and help you truly personalise your prescriptions…because the ‘invisible (biochemical individuality, oxidative stress, genetic probabilities, subclinical states, imbalanced or burdened processes etc)  just became visible’.   I started requesting lab results early in my career and years later was lucky enough to be taken under the wing of Dr. Tini Gruner.  I found some of our shared notes, from 10 years ago, scribbled all over patient results recently and I was struck by just how lucky I was to have her encouragement to really pursue my interest and how she was a guiding force about learning to recognise pathology patterns over single parameters.  A decade on I can confess, much of clinical and educative success has come off the back of this foundational skill-set and I know, this is true for so many I’ve taught too.  

“The guidance I’ve received over the years from Rachel in relation to pathology interpretation has been one of the most valuable (and fascinating) investments I’ve made as a clinician. Her teachings have filled gaps in my knowledge base I never knew needed filling and have significantly enhanced my understanding of the inner workings of the body! Rachel has an incredible ability to make the numbers that patient’s so often present us with, both understandable and clinically meaningful. The knowledge I’ve gained by investing in this skillset has paid off in dividends and I’m certain will continue to do so into the future.”

Stacey Curcio – Cultivating Wellness

I hope you’ll join me for the most exciting up-skilling opportunity in learning labs yet. Oh…and all this talk about thyroid testing..that’s just a serving suggestion 😉 this year my MasterCourse is focused on the most routine labs of all: ELFTs, FBE, WCC, Lipid and Glucose Panels…an absolute treasure trove of free integrative health information about your patient!

This skillset has been found by many to be biggest ‘game-changer’ in Integrative Medicine!

There are limited places. To sign up for the MasterCourse: Comprehensive Diagnostics click here.
For more information about the program click here.

Is Your GP Doing it Tough Right Now?

If you receive the free Medical Observer newsfeeds you’ll know what I’m talking about.  Here are some recent headlines:

I stand accused of rorting Medicare.  This is what it’s like

A GP is sued after doing everything right — except her notes 

After-hours funding shakeup

‘We’re becoming unviable,’ says GP hit with $22K e-PIP repayment

This Christmas I wish for doctors to feel valued again

So the answer is, probably.  Tales direct from the trenches that I hear from GPs, suggest it is increasingly difficult to make a living without adhering to a crazy volume of <10min appts, without being sued (too often) or dragged in front of AMA or APRHA. I hear them and know that the increased pressure is coming from multiple angles and I think it is very sad that previously such a respected and valued role in society appears to be ‘losing its value’.  Don’t get me wrong, I don’t agree with the old ‘Doctor as God’ model and think it ‘s very unhealthy actually for patients, but I feel like GPs with all their extensive training, knowledge and expertise are in urgent need of an Oprahesque ‘new dawn’!  (more…)

End of Year CD Clearance

As we head rapidly towards the change over of our calendars we would like to offer you a special on the very best educational recordings from 2014 – buy 2 CDs before Jan 31st and receive one complimentary Premium Audio Recording of your choice  OR purchase 4 CDs and receive a 3 month Premium Audio subscription for free

It’s been a busy year during which Rachel has delivered 7 very successful new seminars in the area of mental health and  beyond, most notably fortifying her role as a leader in the field of diagnostics and pathology interpretation.  This has included collaborations with ACNEM, Biomedica, Health Masters Live, MINDD and Nutrition Care, however, each recording is classic Rachel – full of fresh perspectives on diagnosis & treatment, colourful analogies  & humour.  In case you missed some of these this year or want a copy for keeps – here’s a quick summary of the 2014 recordings included in this end of year offer: (more…)

Dear Doctor …

As most of you know, I’m a big fan of establishing good communication with the other practitioners (GPs, psychologists, osteopaths, specialists etc.) also caring for my patients and what began as occasional letters that I found exasperatingly difficult & time consuming to write has become second nature.  That’s not to say every letter I write now hits the spot & evokes the desired response but I think I’ve got a pretty good run rate.  So I put together some tips that I thought might help you either get started or get SMARRRTer at it! :)

  • S – Service
  • M – Medical language & conventions
  • A – Accuracy
  • R – Reasonable
  • R – Rationale
  • R – Respectful
  • T – Time-conscious

Service

  • A summary of the most important medical aspects of the case is a great time saver for other health professionals & assists them in making better informed clinical decisions
  • Summarise key points of reference
    • e.g. Betty Smith (BMI 36kg/m2, Waist 92cm)
    • e.g. Depression (diagnosed 2010, Zoloft 100mg/d)
  • Pick out the salient features of the case
    • What are the absolute must-knows in the case?

Medical language & conventions

  • Only use medically accepted terms & diagnoses
    • e.g. avoid naturopathic speak such as dysbiosis, adrenal fatigue etc.
  • Quantify EVERYTHING relevant
    • e.g. weight loss/gain (7kg in 3mo), DASS scores, stool Bristol type & frequency
  • Include all units of measurement
    • e.g. 4.6 mmol/L, 129/84 mmHg
  • Summarise medical hx in table form for easy reference

Accuracy

  • Clarify which details you have first-hand Vs second hand – be careful not to be part of Chinese whispers
    • e.g. patient reports being diagnosed with lactose intolerance
  • When including patients’ own words – use quotation marks
    • e.g. patient reports feeling “dizzy & vague with brain fog most days”
  • Clarify if some things have been self-prescribed – otherwise the assumption will be that you gave/recommended it to them

Reasonable

  • Don’t use a scatter gun approach when suggesting investigations
  • Try not to ask for subsidised testing that the GP is simply unable to do under subsidy
    • e.g. Full thyroid function test can’t be subsidised without a prior diagnosis of thyroid disease or TSH outside of reference range…WEIRD BUT TRUE

Rationale

  • Present a brief, clear justification for any requests
    • e.g. Iron studies (vegetarian diet)
  • Include appropriate references when the justification is likely to be beyond expected knowledge
    • e.g. as a deficiency of this vitamin has Vitamin D – both 25 (OH)D & 1,25(OH)2 D, been implicated in a large number of autoimmune conditions assessment of both forms is recommended (Smieth et al.  Vitamin D in Autoimmunity. Am J Clin Nutr. 2013)

Respectful

  • Ask for their assistance/insight/review/guidance
    • Don’t forget – you want & need it!
    • Keep in mind also how the relationship your patient shares with this practitioner may be positively or negatively impacted by the respect & tone of your letter

Time-conscious

  • How far in advance should the GP receive your letter in order to give him/her adequate time to read & digest the content?
    • e.g. too close to consult – GP might understandably feel ambushed/rushed/unprepared
  • How much time does a GP or other professional have to spend with each patient?
  • In summary the less words the better –  look for ways to reduce your word count, cut to the chase and ideally get most letters down to 1 page

Happy writing :)