All posts in Dr. Smith’s Articles

Hypothyroidism

Well I know I’m tired, but we do have three young children in diapers and I’m not sleeping well.  It’s probably just normal exhaustion.”

My wife’s explanation certainly made sense, but it was so easy to check a thyroid level that we went ahead anyways.  And low and behold, it showed that besides her “normal exhaustion” she was also hypothyroid (having an underactive thyroid gland).  Once this was treated at least some of her exhaustion eased up.  The rest had to wait until our kids (eventually seven of them) were all sleeping through the night.

So how does hypothyroidism usually show up?  It has many symptoms, most of which are very non-specific.  They include fatigue, dry skin, cold intolerance, constipation, weight gain, hair loss, depression, and menstrual disturbances.

And what causes it?  Worldwide iodine deficiency remains the foremost cause of hypothyroidism.  But in the U.S. where iodine intake is adequate, autoimmune thyroid disease (also called Hashimoto’s disease), is the most common cause of hypothyroidism.  In Hashimoto’s disease one’s own immune system is slowly attacking and knocking out their thyroid gland.

Hashimoto’s disease sometimes also shows up with temporary throat pain, full-out exhaustion or painless thyroid enlargement.  If left untreated long enough (rare in the U.S.), hypothyroidism can eventually lead to myxedema coma where a person exhibits marked fluid retention, slowed mental status and even heart failure.

If you’re one of the legions of folks who are fatigued and perhaps struggling with weight gain, the odds are it won’t turn out to be hypothyroidism.  But then again, it’s easy to check and if it really is hypothyroidism then you have something you can readily treat and improve.  The most commonly recommended blood test is called thyroid stimulating hormone (TSH).  If your thyroid is going low, the TSH will go the other way and be abnormally high.  If that turns out to be the case, thyroid hormone levels and thyroid antibody levels can also be checked to define the type of hypothyroidism.

About the only type of hypothyroidism to still have a normal TSH is something called euthyroid sick syndrome or nonthyroid illness.  In other words, if a person has some other severe illness their thyroid may partially shut down until they begin to recover.  There is some controversy as to how to treat these cases but the main approach is to treat the underlying severe illness which then allows the thyroid to recover on its own.

For being such a small gland, perched like a plump butterfly at the base of the front of the neck, the thyroid exerts an amazing amount of control on the rest of the body.  So if you’re getting symptoms suggesting that your chubby butterfly is getting sluggish, get a blood test.  It’s easy and it may allow you to only have to wrestle with “normal exhaustion.”

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Bursitis: Water on the Elbow

So what’s this little water balloon on my elbow?  Doesn’t really hurt; just feels kind of weird to rest my elbow on anything.  And I didn’t really do anything much to hurt it as far as I know.”

To cut to the chase, this patient had something called olecranon bursitis.  Olecranon is just the name of that part of the elbow, and bursitis is just the term for an inflamed bursa.  So what in the world is a bursa?  It’s a fluid-filled sac that is located at a joint and serves to reduce friction over some of the moving parts of that joint.  Picture a small balloon deflated until it has only a tiny amount of fluid in it that serves to help it cushion and reduce friction.  There are about 160 of these bursae in the human body distributed throughout the joints.  For example, the knees each have eleven bursae.

These little lubricating sacs do an amazing job reducing the wear and tear of the bones, ligaments, tendons and cartilage that are moving over a lifetime in each joint.  Once in a while one of these bursa gets inflamed (actual infection is much less common), swells and may become painful.  Most of us will experience one or more cases of bursitis at one joint or another over the course of a lifetime.

Typically bursitis of the knee, hip or shoulder is painful, perhaps in part because there is pressure on the inflamed bursa due to their location.  The olecranon bursa sits over the point of the elbow and is free to swell without much pressure.  The result is that it usually is only minimally painful or even painless (though occasional painful cases occur) and is just a funny-looking nuisance hanging off of the elbow.  It may show up after falling onto the elbow or just from routinely leaning on the elbow.

As far as treating olecranon bursitis, some choose to do nothing but wait it out.  If this is chosen, a neoprene sleeve or similar application may be helpful to reduce swelling and minor trauma to the elbow.  With this approach the inflammation may calm, the swelling then eases out of the bursa and the problem resolves.  This can take from weeks to months and sometimes doesn’t seem to be progressing at all.

The next level of treatment is to use oral anti-inflammitants (like ibuprofen or naproxen), icing and attempts to avoid putting pressure on the bursa.  If this still isn’t bringing resolution, your doctor may offer to drain the fluid from the bursa and inject a small amount of cortisone (a steroid) along with a numbing medicine back into the bursa.  This has a somewhat better than 50-50 chance of resolving the problem.  Worst case if after a couple of these attempts the fluid just keeps coming back, an orthopedist can be consulted.  The last resort is the surgical removal of the bursa if it persists in staying swollen, inflamed, and is doing more harm than good.  Similar approaches are taken with other types of bursitis, many of which are significantly more painful than olecranon bursitis.

The bursae are another amazing and ingenious part of the creation that is our body.  Like most of our other parts, we tend to not really appreciate and notice them until they aren’t working quite right.  So if you have some joints that are still moving with a degree of smoothness, thank your Creator.  If you’ve got symptoms that sound like bursitis, it might be time for a little treatment.

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Direct Primary Care

Article update: To learn more about Trinity’s Direct Primary Care program please visit www.trinitydpc.com or call our DPC headquarters at 865-244-1800.

Two weeks ago we talked about the challenges of today’s medical care.  Without repeating ourselves too much, it boils down to patients paying more and more for insurance that seems to cover less and less.  At the same time we see ourselves giving more and more control of our care to insurance companies and government entities rather than leaving our health care decisions to ourselves and our physicians.

On the physician’s end there is the same sense of having medical decisions taken over by insurance companies and government entities that have never seen our patients.  And these entities require us to spend ever greater amounts of time on bureaucratic and documentation chores which take us away from a direct focus on the care of our patients.  So, can anything be done beyond going into a rant?

There are a number of things that can help.  This week and again in two weeks I want to discuss two straightforward but exceedingly helpful responses to the problem.  I believe they would help rescue us from drowning in cost-prohibitive and impersonal health care run by distant entities.  This week, I’d like us to consider Direct Primary Care (DPC).

DPC practices are a growing part of the delivery of primary care – the routine preventive and sick care that for most people makes up about 80% of their medical care.  DPC offices make agreements directly with their patients to provide care at a set price by cutting out the middleman of insurance.  Because the extra time and overhead of dealing with insurance regulations and jumping through endless hoops and restrictions is eliminated, healthcare is able to be delivered efficiently, affordably (for about the price of a basic monthly cell phone contract), and personally. Less expensive catastrophic or major medical insurance to cover the possibility of hospitalization or expensive specialist visits is still encouraged.

DPC has been shown to provide superior health outcomes compared to traditional medical set-ups.  This isn’t because DPC physicians are any smarter than those in traditional models; they simply have more time and less distractions from focusing directly on the patient and their needs.   In DPC models visits are not only more focused on the patient, but are able to be longer and same or next day availability is easily arranged.  These practices generally pre-negotiate less expensive x-ray, MRI and other imaging and are able to offer most routine labs, EKG and other basic primary care services at no additional cost.

In many ways, the advantages of DPC only make sense.  Insurance is normally used for covering less likely but major events (as would be covered by catastrophic medical insurance).  Routine primary medical care becomes tied up in knots and is far more expensive when insurance companies are put in charge of it.

So who does this really make sense for?  Most people with a significant deductible (which is the vast majority of policies these days) will find DPC a very affordable, if not outright much less expensive, option.  Of course for those with no insurance a DPC arrangement is an ideal solution.

Even for those on Medicare or the few who still have premium insurance plans covered by their work, DPC still makes sense.  With their additional time to focus on prevention, wellness and complete patient care, even if there is (possibly) a slight increase in cost for these specific patient groups, the improvement in the health care experience, access, and outcomes still makes DPC a huge value.

Well there are more questions than we can tackle in such a brief article.  But after looking at the DPC model for a long time and asking a lot of hard questions, I’m a huge fan.  I love the opportunity of putting primary health care back in the hands of patients and their physicians while dramatically driving down its cost by taking out the middle men.  It won’t fix every part of medical care, but it will go a long way in the right direction.  I’m so convinced of this that we plan to change our Maryville office to this model January 1st of 2016 and I am greatly looking forward to taking a large step back in the direction of affordable, personalized patient care.

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The Times They are a Changing

I am blessed by the fact that I really do love what I do as a physician.  I love seeing folks every day and seeking to sort through the problems they’re struggling with, figure out what malady is underlying their symptoms, effectively treat it, make plans with them for preventing other big problems down the road, and along the way, get to know them personally.

At the same time, I can’t help but notice that many of my colleagues feel hassled and unfulfilled and are retiring early.  Likewise, patients feel that medical care is more and more frustrating with big bills, short visits, and impersonal, distracted interactions with physicians.  With insurance they pay more and more to get less and less coverage while losing more and more control over how and what they receive in medical care.

For my part, I feel those same pressures on both me and my patients.  When I began practicing medicine, I could still readily focus on my patient, take the time I felt was needed with them, decide what further tests were necessary to arrive at a diagnosis for them, choose which prescription or course of treatment would be most effective, document a note in a minute or two, and charge a reasonable fee for the service.

Now my patients and I feel competing, resisting, and frankly annoying forces at each step.  It’s harder to focus attention on my patients because insurance companies and government agencies require massive, multi-page notes full of minutia that helps neither me nor my patient and takes my eyes off the patient and on to a computer screen.  To try to solve this I finally hired a full time medical scribe to help keep the notes so that I could focus back on my patients.

Next when, after hearing from and examining my patient, I decide which tests are needed to help diagnose their problem, I often need to battle with the insurance company to convince someone who has never seen my patient that the test is necessary.  This involves more time from me and my staff and often delays diagnosis for my patients.  Next comes the course of treatment.  It is no longer just which treatments or prescriptions would be best, but the all-important question of what insurance will allow and cover.

I could go on but you get the picture, and as patients you’ve experienced it.  The personal doctor – patient interaction is being taken over by distant, impersonal entities steadily engulfing every step of medical care.  Time, attention, and cost are increasingly going toward satisfying these entities instead of taking care of individual patients.

So what’s the core of the problem, and is there a reasonable fix?  The answers to those questions are larger than a column this size can fully tackle.   But maybe with this and another in two weeks we can make a helpful start.

We can count on the fact that the one paying the bills for medical care will eventually control the care.  When we moved to a system of insuring medical care at every level we started down the road that has brought us to this place where patients and their physicians are no longer in control of care.

Normally insurance involves many people pooling their resources to be able to afford to pay for an unlikely but expensive event.  So catastrophic medical insurance makes sense. But we don’t use our homeowners insurance to cover repainting a room, or our car insurance to cover an oil change.  Likewise, we shouldn’t use medical insurance to cover every physical or strep throat.  These are routine, expected services.  When we began to use insurance to cover all of them, the total cost began to go up and the control of the visit began to be taken away from the patient and their physician and given to the insurance company or government agency.

Each time a large entity such as an insurance company or the government promises or implies that they will take care of us, we need to remember that sooner or later there will be a very substantial cost, sometimes in dollars, and sometimes in loss of control over every level of the medical care we receive.  Experience has borne this out.

Ok, so that is a very brief picture of some of the problems facing us in getting affordable, effective, personal medical care.  It is not at all intended to be a rant a whine or an idle complaint, just an objective look at where we’re at in medical care.  It is an attempt to diagnose the cause of our problem.  And I believe there may be a cure for the cancer that is eating up medical care, or at least some steps that can put it into remission.  But, as you so often may hear from your physician, we’re out of time and that will have to wait for two weeks from now.

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