We recently had a new patient, 75 years of age, who has class I obesity and prediabetes, and has had hypothyroidism for over 25 years. She is very active and has purposely lost weight, about 6 pounds. She told me she has had hair loss over the years and has seen a specialist for this, but lately it’s been worse. She takes spironolactone, biotin, and zinc for her hair loss. She wanted to know what she could do about her hair. She is taking 150 mcg levothyroxine and 5 mcg liothyronine.
Although her physical exam was unremarkable, we consulted with an endocrinologist who recommended lab studies, thyroid function tests and testosterone levels. We actually thought it was most likely her thyroid. Besides her regular labs that were due — CMP, CBC/diff, Vitamin B12, D, A1C, Lipids, which were all unremarkable — we drew a TSH, Free T4, Total T3, Free T3, Ferritin and free and total testosterone. All were unremarkable except the TSH her TSH was suppressed and her Free T4 was high at 2.4.
When we received her lab work, we thought it was her thyroid. We contacted her by phone and recommended she decrease her dose of levothyroxine. She fought this recommendation saying, “I’m fine. I’ve taken this dose for over 25 years. Isn’t there some type of supplement I can take?” We then recommended she meet with an endocrinologist for a workup and let her know, “If your thyroid levels are off, this needs to be looked into. This could very well be the cause. This is why we perform thyroid tests on a regular basis.” She did agree to come in to meet with the endocrinologist for thorough workup and discussion.
Knowing many patients don’t like to be informed of change, especially that medication dosages can change with age, I held off on that one on the phone, leaving that to be part of the conversation with the endocrinologist in person. In my experience, patients (people) don’t like to hear about age-related changes, be it the diagnosis of diabetes, needing to take insulin, hypertension, hyperlipidemia, and the list goes on. For most, if it can wait, best to discuss in person.
- It’s not what you say to a patient, but how you say it and “where” you say it. Knowing your patient can guide you sometimes but not all the time. See “What NOT to Do When Your Patient is a Colleague.”
- The telephone is often not the best way to communicate what may be considered bad news.
- Many patients will tell you their older parents or grandparents had this or that, but not them. They’ve always had normal levels of blood pressure, lipids, glucose, etc. Many times we must tell them these are age-related and it’s happening to them. People don’t like to hear they are getting older and yes, it is happening to them too, and yes, genes may not be all of it, but in many genes do matter.
- When discussing what seems shocking or disastrous to a patient, always give them hope.
- The way we communicate can avert disasters we may not even be aware of; stress can be disastrous. We need to do our best to communicate in a manner that may not fully prevent the stress, but can be less stressful to our patients.
Joy Pape, FNP-C, CDE
Medical Editor, DiabetesInControl
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