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The Mask

Each day, more and more scientists release new information into the cloud of gnosis. Anyone can access these mysteries of knowledge, but getting the proper information about any subject requires perseverance and understanding. When a problem arises, the direction in which one gazes at the opportunity determines the possible solutions. Vision is our greatest ally in problem-solving. The same holds for solving the riddles of the body. Cells communicate with each other via chemotaxis. The entire immune system unifies under the direction of tiny molecules and membrane receptivity. Cells do not have eyes; they have receptors. Cells react to carefully constructed carbon-based molecules that are secreted by a diverse population of tissues, glands, and organs.
 
Fatigue plagues our American population more than any other symptom. Eighty-five percent or more of our patients complain of fatigue regardless of their illness(es). Most of our patients find very little help in overcoming their fatigue from the industrial healthcare machine. It seems as if practitioners have no time to look for reasons why fatigue exists. Most times, it is more convenient for a physician or a nurse practitioner to deny fatigue as a symptom and replace it with depression or lack of will. How many times have we been told, “It’s all in your head.”?
 
Fatigue is an illness that has a thousand faces. It seems as if it is the most common reason why people lose their way. Fatigue makes cowards of the brave. Exhaustion takes away the joy of discipline. Tiredness makes the energetic lazy. Fatigue makes the brilliant thoughtless.
 
Why is fatigue so prevalent, almost pandemic? Regardless of the source of fatigue, it becomes the final common mechanism to stop people in their lives once their health degenerates beyond repair. Humans are built to handle a large amount of physical and psychosocial stress. Unfortunately, society tells us that we can have it all. We strive to give our children every opportunity to experience the world; school from eight to three, sports, sometimes two per season, music lessons, sometimes two instruments at a time, church school and youth group, boy and girl scouts, volunteering at the homeless shelter, extravagant vacations, big birthdays, and special social events. Parents run themselves ragged as they work full-time to support all of their dreams for their children. When there is more than one child in the family, complex arrangements are necessary to satisfy everyone’s desires all the time.
 
Humans are nothing more than a sack of bacteria floating in a sea of hormones. Regardless of anyone’s age, hormones matter. Chronic, unrelenting, episodic stress in all of its forms can reduce the secretion of most of our anterior pituitary hormones. That close-knit gang of hormones runs the human body with the help of the thyroid and adrenal glands. In the last five years, the lay public has rebelled against the unfortunate and insensitive approach to thyroid-related disease management by the majority of overworked specialty saboteurs called endocrinologists; those same specialists who tell people with diabetes that simple and complex carbohydrates are essential for healthy living when sugar is poison to their body. The standard endocrinologist’s answer to high blood sugars is to dial in more subcutaneous insulin: the more insulin, the better. Scientists are now showing that excess insulin is profoundly detrimental to the heart and brain, manifesting in heart attacks and strokes, especially in people who have diabetes.  Years ago, doctors prescribed arsenic to patients who had syphilis. Now we use penicillin, thank goodness.
 
Reports show that practitioners all over the world are embracing new substitution or replacement strategies for all hormones deficiencies. The last to change their habits are those in the academic world - those medical school professors in their fifties, sixties, and seventies who practice in ivory towers. And, they have loud, authoritarian voices spuing traditional, old-fashioned treatment algorithms that left medical practice when the tincture of iodine, digitalis leaf, and cotton balls became things of the past.
 
Infectious disease experts are also a group of specialists that have a long way to go. They base their thoughts about infection, both acute and chronic, on old understandings of the immune system. Polly Matzinger, immunology's dangerous thinker, has shown much light on the shadows of immunology. Her research has significantly challenged our perceptions about our body’s defenses against viral and bacterial infections. She is a pioneer in her field. Chronic, active infections cause fatigue and many times go unrecognized and untreated.
 
The list of specialists who lack concern about fatigue grows every day. Autoimmune disease is a public health concern of the first order. Rheumatologists also fail to embrace Dr. Matzinger’s ideas related to the immune system. Psychoneuroimmunologists have demonstrated that stress and chronic active infections directly correlate with autoimmune disease. The rat and mice models are reproducible. Someone needs to build a bridge between the islands that are inhabited by these two specialties so they can communicate about prevention and cure of autoimmune disease if they are the ones getting the grant money to research them.
 
The greatest failure of our medical system is the absolute lack of generalists who take the complaint of fatigue seriously. I am a generalist and proud of it. We are the ones who are supposed to integrate the recommendations of specialists into solid treatment plans since specialists give little concern for other specialists’ recommendations as it pertains to the whole of the patient. We are the ones who are supposed to push the specialists for better answers to complex problems. No specialist wishes to consult; they have a desire to control. That is a dangerous situation for the patient in all ways. I understand the need for patients to take control of their health in today’s industrialized healthcare delivery system. They deserve better from all of us.
 
There is no debate: Americans have the best trauma and emergency care system in the world. However, we physicians fail miserably at caring for chronic, active fatigue. Basic science has shown that thyroid regulation is much more complex than measuring a Free T4 and making sure the TSH is within the normal limits which varies depending on the laboratory doing the testing. The idea that the normal TSH range is ten-fold (0.4 to 4.15 mIU/L) is absurd. I agree that if we randomly measure TSH in 10,000 people who report having normal thyroid function, the 95 % confidence range maybe 0.4 to 4.15 mIU/L, but on an individual basis, the range for normal TSH is much tighter. Hypothyroid and hyperthyroid patients are in the normal study population. Physicians did not diagnose them properly at the time the researchers created the normal reference range.
 
What is even more absurd is that academic endocrinologists have decided that if a patient has a TSH lower than 0.4 mIU/L, and has a normal Free T4 level, they should be diagnosed with subclinical hyperthyroidism, especially if the patient has no clinical sign of too much thyroid in their system. Examination of the normal bell-shaped curve reveals that 2.5 % of patients randomly tested will fall three standard deviations from the mean which lands their TSH below 0.4 mIU/L. If the normal range is tenfold, certainly patients with low TSH levels determined on a random basis should be considered normal, not subclinically hyperthyroid. If someone has a random TSH result above 4.15 mIU/L, physicians are hesitant to diagnose subclinical hypothyroidism if the Free T4 is low-normal. I have witnessed several patients with low-normal Free T4 levels and TSH measurements as high as 11 mIU/L.  Their endocrinologists have told them that their fatigue, constipation, dry skin, and weight gain is a result of poor eating habits and mental laziness. One girl, fifteen-years-old, was told that she was “just plain fat.”
 
All too often, fatigue is a complex medical condition that requires several changes to reverse. Physicians must keep an open mind when interpreting clinical laboratory testing. No one is born with an operating manual. Individual genetic testing cannot reveal the ideal TSH, Free T4, Free T3, and Reverse T3 levels for each patient. Even if that breakthrough occurred, medical insurance would not pay for the analysis because it would be considered experimental. The bottom line is that symptoms of low thyroid remain the mainstay of diagnosis, and trials of small amounts thyroid medication are helpful in determining whether a patient’s fatigue is due in part to a clinical manifestation of insufficient levels of thyroid hormones.
 
To all my generalist colleagues, please start looking after fatigue patients with the vigor and hardiness that you would cancer or heart disease patients. Spend time with them and look for any possible reason why fatigue would compromise their health. We all went to medical school and residency to practice medicine. We did not go through incredibly demanding training to send everyone out of our practices for consultations with multiple specialists just to say we did everything we could to diagnose the patient. Those of us who do just appear to be a physician.
 
To every patient we evaluate for fatigue, we just don’t wear the mask of the doctor; we are the doctor.
 
Then be the doctor.
 
 
Doc
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