# Graves, nodule, refused RAIU



## pitseleh (Jan 22, 2011)

Hi everyone-
This is my first post, though I've been lurking for a while. I'm 33, was diagnosed with Graves in the Spring of 2009 and have been taking Methimazole ever since (I now take 10mg of Methimazole a day, and my labs are at euthyroid levels). In that time, I've had 2 thyroid ultrasounds. Each time, a small nodule was found on the left side deep within my thyroid.

My first endocrinologist didn't even mention the nodule- apparently it's oval-shaped, and on one dimension/axis, the diameter is small enough to not be a cause of concern; on the other dimension, it's just big enough to deserve further investigation. She may have briefly mentioned it when it appeared on the second ultrasound, but felt it was nothing to be concerned about. I should add: she was with the Cleveland Clinic, and received a lot of praise on http://www.thyroid-info.com/topdrs/, so I trusted she knew what she was doing.

That endo went on maternity leave and never returned to the practice. I've begun seeing a colleague of hers, who saw my ultrasounds in November and right away recommended RAIU and FNA. I asked for some time to think it over and do some research. I am adamantly against putting radioactive anything in my body, and told her so. I put off the RAIU and FNA these past two months. I believed that if doc #1 didn't think it was a big deal, then it wasn't a big deal. I believed doc #2 was jumping the gun just a bit.

[sidenote: She seemed to be jumping the gun on lots of things. She told me I have a heart murmur, when I was seen by a Cleveland Clinic cardiologist last year and he didn't notice it. She seemed to think the idea of an armpit thyroidectomy (which I read about on this forum) was preposterous and that I was being ridiculous for asserting that if I had surgery, I'd prefer one of those. She is very willing to order lots and lots of tests. On my thyroid. On my hormones. On my blood sugars. (I had to tell her that, no, I did not want to be tested for diabetes, that, no, I'm pretty sure I don't have diabetes, that I am 99% positive I've got hypoglycemia, that yes, I know how to deal with it.)]

Anyhow, I saw endo #2 again this week. She again asked about a biopsy. She said she would be willing to forego the RAIU, if I was still opposed to the radioiodine, and simply do an ultrasound-assisted FNA. The RAIU, she said, is just prelude to the FNA anyways, and the FNA is "where the money is," results-wise. This sounds great to me, as I have a "limited benefits" insurance plan that maxes out at $10k a year. The fewer procedures I ask them to pay for, the better.

My questions for you guys: is this foolish of me? Should I have the RAIU anyways? Does it make a difference? Also, I've found anecdotes online-- namely, here: http://www.medicinenet.com/thyroid_cancer/discussion-126.htm -- of patients having FNAs that did NOT detect their cancers. Now my anxiety is ramped up so high all I can do is fret and cry and fret some more. Do any of these tests really make a difference when false negatives are so common? Should I even bother with tests, or should I just have the poor thing (it's not its fault) surgically removed?


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## lainey (Aug 26, 2010)

Hello, and welcome.

The smaller the nodule, the more likely it is that you will get indeterminate results. If the nodule is also located deep in the thyroid, it will also be more difficult to biopsy accurately.

Has the nodule been changing in size, or has it been stable?

The robotic surgery is one of the newest, hottest techniques for thyroid surgery out there. If your endo doesn't know about it, then I would question how up-to-date they are on new information in their field. This would cause me to question their opinions in other areas.

Are your symptoms well controlled on the methimazole? Has anyone suggested at this point that you trial going off of it completely to see if you are in remission? Given that you have been on methimazole for almost 2 years, I am wondering what course is planned for that, as doctors typically don't leave patients on these medications indefinitely--if you go into remission, fine, if not then ablation is recommended.

So you see, you have more than one reason to potentially discuss surgery.

Why are you so adamantly opposed to RAIU? You realize that if the nodule were found to be cancerous, that may be part of your adjunct therapy? Do you refuse regular x-rays also? If so, are you aware that a simple trip on the plane exposes you to the same amount of incidental radiation as a common x-ray?

RAIU is an important tool for the diagnoses and treatment of thyroid disorders. The beauty of it is, it is specific to thyroid tissue and has a short half life so it is flushed quickly from the body. Doses are tailored to the needs of the patient--your overall exposure is limited.

Anyway, I'm thinking a second opinion on your situation might be in order, considering what you are saying about the current endo. Given your insurance situation, you might get copies of your current results and get another doctor to look at them as a consultation without running further tests first.


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## Andros (Aug 26, 2009)

pitseleh said:


> Hi everyone-
> This is my first post, though I've been lurking for a while. I'm 33, was diagnosed with Graves in the Spring of 2009 and have been taking Methimazole ever since (I now take 10mg of Methimazole a day, and my labs are at euthyroid levels). In that time, I've had 2 thyroid ultrasounds. Each time, a small nodule was found on the left side deep within my thyroid.
> 
> My first endocrinologist didn't even mention the nodule- apparently it's oval-shaped, and on one dimension/axis, the diameter is small enough to not be a cause of concern; on the other dimension, it's just big enough to deserve further investigation. She may have briefly mentioned it when it appeared on the second ultrasound, but felt it was nothing to be concerned about. I should add: she was with the Cleveland Clinic, and received a lot of praise on http://www.thyroid-info.com/topdrs/, so I trusted she knew what she was doing.
> ...


Hmmmmmmmmmm! Welcome to the board. It is your decision to make; after all, you are the owner of your body!

Can you share your most recent labs with the ranges intact? Do you feel euthyroid? Have you had your liver enzymes checked as Methimazole is very very damaging to the liver w/long-term use?

How were you diagnosed w/Graves'? Do you have Exophthalmos, goiter, pretibial myxedema, thyrotoxicosis?

Have you had antibodies' tests?

TSI (thyroid stimulating immunoglobulin),TPO (antimicrosomal antibodies) TBII (thyrotropin-binding inhibitory immunoglobulin), Thyroglobulin Ab, ANA (antinuclear antibodies), (thyroid hormone panel) TSH, Free T3, Free T4.

You can look this stuff up here and more.........
http://www.labtestsonline.org/unders...s/thyroid.html

High titers of Thyroglobulin Ab "could" indicate cancer. You could do this much, maybe?

As far as I know, there is no harm done w/ RAIU but as I say, "It is your decision to make." I do respect that. We all do.

We are here to be supportive no matter what your decision.

It does just so happen that Graves' and cancer are bedfellows.
Graves' and Hashi's cancer
http://www.thyroidmanager.org/Chapter18/18-cancothr.htm


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## pitseleh (Jan 22, 2011)

Hi guys,
Thanks for your replies. Here's a little more information:

Current labs:
TSH (0.400 - 5.500): 1.34
Free T3 BLD (1.8 - 4.6): 2.8
Free T4/ Free Thyroxine (0.7 - 1.8): 0.9

My TSI was measured in 5/09, just after beginning medication; it was 7997. I have no range for this-- it simply states "Low: <150% Normal." Clearly I wasn't low, but I sure don't know what normal is supposed to be, so I don't know how high I was, either.

My TBI was also measured in 5/09; it was 18.5. Again, no range given, just "Low: <1.0 U/L."

Haven't had TgAb, TPO, or ANA tested, but will ask about them. Not sure if it's necessary, since my sky-high TSI is likely the cause of the Graves, right?

I found out about the potential liver problems (thank you, Mary Shomon) and requested I be tested for liver function and white blood cell count. Again, the docs thought I was being a hypochondriac, but they humored me and checked. Everything was and is normal.

When I was diagnosed, I was presenting a few symptoms: resting pulse of 120; two recent episodes of fainting; weight loss; hand tremors to the point that I couldn't recognize my handwriting; leg muscle weakness; ankle edema; nausea; jitteriness; and very slight exophthalmos. But no thyroid storm (is that what thyrotoxicosis is?), no goiter (my thyroid was enlarged, which they medically termed "toxic diffuse goiter," but I had no goiter per se), no pretibial anything. I have seen you post those criteria elsewhere on here and it got me wondering, since I had so few of the symptoms needed for determination- aren't we supposed to have 3 out of the 4 for a diagnosis?

As for my ultrasounds:
May 09:
Right lobe 5.7 x 2.5 x 2.8 cm
Left lobe 5.6 x 2.8 x 2.7
Findings:
There is a homogeneous hypoechoic nodule along the posterior aspect of the left lobe of the thyroid. This measures 1.1 x 0.7 x 0.9 cm in size. This could represent a parathyroid gland.
Impression:
1. Enlarged heterogeneous thyroid. This can be seen with thyroiditis or other causes for hypothyroidism.
2. Soft tissue nodule along the posterior aspect of lower pole of the left lobe of the thyroid probably represents a parathyroid gland.

May 10:
Right lobe: 6.8 x 2.9 x 2.4 cm
Left lobe: 6 x 2.4 x 2.9 cm
Gland echogenicity demonstrates heterogeneous exchotexture with hypoechic lesion within the inferior left lobe measuring 1.4 x 0.6 x 0.7cm. 
Impression:
Diffusely enlarged, hypervascular thyroid which can be seen with Graves' disease or thyroiditis; fairly stable hypoechoic lesion inferior left lobe.

I'm concerned this doc is mistaking a parathyroid gland for a nodule. Should I opt for RAIU to rule this out? I am concerned about the radiation because, namely, radiation is bad for you. Radiation kills cells. Radiation makes you a biohazard. And all the reasons mentioned here: http://www.suite101.com/lesson.cfm/19330/2902/3. I do understand that the dose for RAIU is the lowest possible, but can't it still cause some problems?

Lainey, doctors do allow patients to take anti-thyroid drugs indefinitely-- doctors in Europe and Asia, that is. I've found articles on PubMed from medical journals that looked at cross-cultural approaches to treatment and found that in most first-world/ developed countries, ATDs are the first line of defense. It's primarily North American doctors who want to jump in and immediately kill off/cut out the thyroid. It is not untypical to find folks in France, for example, who take a daily management dose of 5mg in order to keep themselves in remission. I have been requesting the docs slowly reduce my dosage based on how I feel. I tell them when I start to feel hypo, and they lower it by 5 or 10 mg. I am down from 30 or 40mg/day to only 10mg/day. I know it is not ideal to take ATDs long-term, but I believe I can reduce my risk of liver problems by taking the lowest possible effective dose.


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## lavender (Jul 13, 2010)

I had RAIU before my thyroid was removed, and I chose surgery particularly because I did not want to have RAI ablation. My endo basically told me it would be necessary for my surgeon to prepare for my surgery. Looking back, and having learned a lot more, I am not sure that was true, but it was done and I survived.

I have to admit that I was concerned about the radiation dose from RAIU, but the technician assured me it was minimal and not a threat to others around me. At the same time, I was given a card to carry in my wallet in case I set off a geiger counter in the following two weeks. So, I have to assume it was more radiation than an x-ray because I have never been given a special card for an x-ray.

I did not notice any ill effects from the RAIU, and I am particularly sensitive to meds.

From my understanding, the only way to know for sure if a nodule is cancerous is to have surgery and have someone stick it under a microscope, but there are ways to determine if cancer is more likely. RAIU and FNA are two tools to help determine this. If your gut is telling you cancer and/or you want the gland out, stick with it. But if you are unsure, I would get the tests. They may help you feel more comfortable deciding not to have a costly surgery with all the risks that entails.


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## Andros (Aug 26, 2009)

pitseleh said:


> Hi guys,
> Thanks for your replies. Here's a little more information:
> 
> Current labs:
> ...


You sure are good at keeping records and advocating for yourself; I commend you on this.

You do have a very ill thyroid there, that is for sure. And clearly the TSI is responsible for your hyper. My eyes popped when I read the number. The only reason there is a range is to detect movement to see if the patient is responding to treatment or not.

Here is the skinny on TSI. The healthy patient should have none.

TSI
Normally, there is no TSI in the blood. If TSI is found in the blood, this indicates that the thyroid stimulating immunoglobulin is the cause of the of a person's hyperthyroidism. 
http://www.medicineonline.com/topics/t/2/Thyroid-Stimulating-Immunoglobulin/TSI.html

W/swollen ankles, you may or may not technically have pretibial myxedema but I do suspect that you might. Good grief; I could not find my ankles at all. So, I am inclined to believe that you do have Graves'. With swollen thyroid, it will take the path of least resistance and not always present as the obvious goiter on the neck.

Be that as it may; the treatment for you would be the same Graves' or not. With the exception of getting w/a Board Certified Ophthalmologist for the eyes as while treating the thyroid does help, the eyes definitely do have to be treated separately whether it is from TED or GED (thyroid eye disease or Graves' eye disease.)

Your Free T3 and Free T4 are both below the mid-range. But I take it you feel pretty darn good? Am I getting the correct impression here, I hope?

Most of us would feel pretty bad w/numbers like that.

If nothing else, we will help you bounce the ball around. It is a good thing to do as it should help you the patient, decide what treatment option is the best for you.


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## lainey (Aug 26, 2010)

Unfortunately, your need to ask for liver function tests once again calls into question the competence of your doctors. Liver toxicity of antithyroid medications is well know, and liver tests should be part of your standard blood work--you shouldn't have to ask for it.

>>doctors in Europe and Asia, that is. I've found articles on PubMed from medical journals that looked at cross-cultural approaches to treatment and found that in most first-world/ developed countries, ATDs are the first line of defense. It's primarily North American doctors who want to jump in and immediately kill off/cut out the thyroid<<

Yes, this is true, but you're not in Europe. In most parts of the world, surgery for a hyperactive thyroid is more of a treatment of choice, whereas here it is seen as a treatment of last resort.

>>I am concerned about the radiation because, namely, radiation is bad for you. Radiation kills cells. Radiation makes you a biohazard. And all the reasons mentioned here: http://www.suite101.com/lesson.cfm/19330/2902/3. I do understand that the dose for RAIU is the lowest possible, but can't it still cause some problems?<<

This link refers to the dosing of radio-iodine to ablate a thyroid. A radioactive uptake scan does not even approach the levels of exposure that ablation does. I have a friend that likes to joke, that in earning his frequent flyer miles, he has been exposed to enough incidental radiation for a lifetime of CT scans. My point is, environmental radiation is everywhere, and you have no way to detect it or avoid it. Yes, you can limit your exposure to medical radiation, but at what point do the benefits of the test outweigh the perceived risk of exposure?

The nodule is quite small. It's likely the RAIU will differentiate between a "nodule" and an inflamed parathyroid. It will also determine how "Hyper" your thyroid still is, based on it's use of the iodine. In the end, the diagnosis of the nodule will only be made with the FNA. At this point, given the small size, your chances of getting indeterminate results is very high.

Not only that, but I bet if you start asking the prices of things, you will find that if you do both, you are going to use up a good portion of your $10,000 right now in the beginning of the year.

With smaller nodules, ultrasound follow-up at 6 months intervals is considered a normal course of action--did the endo suggest that, especially considering the possibliity that it is a parathyroid?


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## msterra37 (Sep 3, 2010)

I am in same boat as you with RAI - after researching..NO WAY am I putting that in my body. I am in touch with the pioneer doctor that does the robotic surgery in Augusta, GA and he has been wonderful. If you have that done and they have to remove it then it inflames the area and makes it harder to do surgery which you probably already know. I have went back and forth..walked the floors...cried..this is awful- but I will bear down and take the surgery in March to get it out of there. The FNA's can not always tell if it is cancer or not--no way to really know unless you get it out of there- that is the part I hate Good luck to you!


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## pitseleh (Jan 22, 2011)

Thank you again for your replies. I learn SO MUCH from this site, it's unbelievable.

Can you tell me what the normal dosage range is for RAIU versus for RAI ablation of the thyroid?

Also, I know there are many precautions you have to take after RAI. Do these same precautions have to be taken after RAIU? Are you emitting radiation after a typical RAIU dose? Are there any studies that have found how much radiation?

Last, I have heard that having RAIU causes you to require a much larger dose of RAI further down the line-- like, the small initial dose makes your thyroid immune to its effects or something, and later you wind up needing to be more heavily zapped by the milicuries than you would have been, if you had not had the RAIU in the first place. (Does that make sense?) Is there any truth to that? Are there any studies about that?

Am I being ridiculous? Yes, radiation is bad. But is this such a tiny amount that I am worried about nothing? I know that many folks on here are very pro-RAI. I would love to hear from folks who are similarly against radiation, but who were willing to concede to having just the RAIU- and not the RAI- done.

One final note, mostly for Andros: No, I don't feel that great. I am tired. All.the.time. (Just awoke from a 3-hour nap! Hello!) Last weekend I was flat-out weak-- could not lift a big bag of dog food. I cannot stand being outside in the cold, but get very warm when I sleep. My eyelids and brow are puffy (to respond to another thing you wrote: I was just seen by a Cleveland Clinic ophthalmologist- the go-to guy for thyroid eye disease. He said if I've got any TED, it's subclinical, and he thinks I'm out of the woods now). I'm so crazy lethargic, all I want to do is crawl into bed and read, but I fall asleep every time I try to do that. Could I be going hypo? Is it possible to have hashitoxicosis with my TSI levels?


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## pitseleh (Jan 22, 2011)

Hey, also- another weird question:

If I want to determine whether that nodule has grown, can I simply multiply its dimensions-- do length x width x height-- to find its volume, and then compare last year's volume to this year's volume?

Likewise, can I do L x W x H to compare the volume of my thyroid lobes to see whether it has shrunk? Because on first glance, it seems to have actually enlarged (RIGHT LOBE! WHAT ARE YOU DOING? FROM 5.7 TO 6.8? WHO DO YOU THINK YOU *ARE*?), but when I did the math, turns out the volume had decreased.

Oh dear. I fear I have now unmasked myself as the terrible nerd I truly am.


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## lainey (Aug 26, 2010)

This took a little while, but first, here is a posted exposure question regarding a radioactive uptake scan. It explains to the 2 types of iodine used, the length of time it's in the body based on the different half lives:

http://www.hps.org/publicinformation/ate/q3540.html

1 mSv is the dose produced by exposure to 1 milligray (mG) of radiation. For radiation, they measure exposure vs. relative dose--hence the different units. The units were developed by calculating theoretical doses thought to cause damage to human tissue.

This article has a lot to say about CT scans, but primarily check out the chart near the bottom, which lists the common dose for a variety of medical scans for comparison. A mammogram, for example gives about 3 mSv of dose. Normal background radiation can account for up to 3mSV also (but a transatlantic flight can expose you to several times that).

http://en.wikipedia.org/wiki/X-ray_computed_tomography

The dose for the uptake scan will be determined actually by your thyroid itself, ie if you are hyper, it will take in a higher dose--it is also the differentiation of the uptake of the structures within the thyroid that gives us the "picture" in the first place.

You are the judge, but the dose from the scan is not much more than any other medical scan--or accumulated number of scans that you have had, or will have.

The I-131 used to ablate the thyroid is a completely different isotope, and different dose than the one used for the scan.

As for your "nodule"--and I use quotes because, it could be a parathryoid, no? You should not put too much faith in the measurements taken by ultrasound. There is quite a bit of room for error here, and considering that 1mm is the diameter of the wire in a paper clip in real life, small variations in the skill and judgement of the technician performing the scan can have a "big" impact here.

The nodule is large enough to monitor, yes, but at this time it is not good to split hairs over it's size or dimensions--simply because of its size, 2 different technicians are going to get slightly different measurements, and a mm in one direction or another is possible on simple human error alone.

What other options are available to you besides the Cleveland Clinic? Subclinical TED, when you are being medicated for Grave's disease, deserves good monitoring--simply because the antibodies can make the thyroid eye disease flare on its own without regard to your thyroid status. Ablating your thyroid with radioactive iodine (should you reach that decision) presents a whole different set of questions when eye disease is present. In my travels, I have heard quite a few negative stories about thyroid endocrinology at the Mayo clinic, for example, so the "name" doesn't always go with the best care. I can only wonder by what you say if perhaps you would get better evaluation and treatment elsewhere.


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## lavender (Jul 13, 2010)

I had RAIU, and I was dead set against RAI. I had it to give my surgeon the best possible info about my case before he sliced into my neck. I also knew that it could help rule out the possibility of cancer. As far as I knew, I was a really low risk for cancer. My case was so classically Graves, and no doctor even mentioned cancer to me until they read the pathology report to me after surgery. I had no detectable goitre, and was not aware of any nodules before my surgery.

The amount of radiation in RAIU is minuscule compared to RAI. I asked the technician if I needed to take any precautions after the test in regards to exposing others to radiation, and I was told no, that the dose was very minimal. This was very important to me because I did not want to expose my significant other. I specifically asked about intimate contact, and was told there was no risk. I have no idea what the dose is compared to RAI because I did not have RAI. Also, RAI doses are different for every patient. From everything I have read, the radiation leaves your body in a couple days. I experienced no side effects whatsoever, and I react to 2/3 of the medications I take.

I can't say I'm totally against radiation. I get x-rays, including yearly dental x-rays. I use a microwave. I went through the x-ray scanner at the airport instead of letting the security staff frisk me (although I will avoid that line when I go back). I even drink the local water, even though I have read that it may be contaminated with radioactive fallout from past nuclear testing, causing abnormally high rates of thyroid disease in Ohio, Michigan, and Pennsylvania.

I just really want to have babies and was not comfortable with the idea of exposing my reproductive system to RAI, even though my endo told me there was no risk whatsoever. I didn't like the idea of waiting months or years while my thyroid slowly died and the possibility that I might have to get RAI a second time. I also figured that if RAI is serious enough that you have to be isolated for days afterward to protect the general public, I did not want to put it into my body. If I had been told I had cancer, I would have had RAI in a heartbeat, but since I have Graves, I felt like there was another option and I wanted to take it.

I am not aware that having RAIU makes RAI less effective. From my understanding, RAIU is a prerequisite to RAI so they can determine what dose of RAI to give you. The technician assumed that was why I was having the test in the first place. Also, RAI uses radio iodine-131. The RAIU test I had used radio iodine-123. According to wikipedia, iodine-123 is used specifically because a much lower dose can be given than if iodine-131 were used, and iodine-123 does not shut down the thyroid as iodine-131 does. Some how I felt a lot better knowing I was taking a different form of iodine that would be given for RAI ablation.

"What risks are there from the test?
The risk from both varieties of thyroid scan is minimal. The amount of radioactivity you are exposed to is comparable to that from a routine x-ray. The amount of radionuclide used is so small that it's unlikely to cause side effects or allergic reactions.

Must I do anything special after the test is over?
No. The vast majority of the weakly radioactive substances used in these tests are cleared from your body within a day or two. But even before then, you can interact normally with other people because there's no risk of exposing them to significant amounts of radiation from your body."

http://www.health.harvard.edu/diagnostic-tests/thyroid-scan.htm

It sounds like you really feel pretty lousy, and I can relate. I know I never felt better on anti-thyroid meds. Even when I was "eurothyroid," I could not function. That's why surgery seemed like such a good option to me. I know I read that some people do very well on the meds and stay on them for many years, but to me, it felt like they were toxic to my system. I am so sensitive to any chemicals, and I knew I would never feel right taking all those meds. Surgery has been a huge relief to me.


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## lavender (Jul 13, 2010)

lainey said:


> This took a little while, but first, here is a posted exposure question regarding a radioactive uptake scan. It explains to the 2 types of iodine used, the length of time it's in the body based on the different half lives:
> 
> http://www.hps.org/publicinformation/ate/q3540.html
> 
> ...


Great articles lainey! Lots of helpful info to sort things out.

I am also intrigued by your suggestion to look outside the Cleveland Clinic. Here in Columbus (about 2 hours south of Cleveland), when I was having difficulty with my endo, a few people suggested that there are no good endos in Columbus, and that I ought to go to the Cleveland Clinic. I have no desire to travel that far to see a doc, and was in no shape to drive that far then, but I was considering it. Luckily, I found a good PCP to help manage my thyroid replacement and am pretty happy with her now.


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## lainey (Aug 26, 2010)

lavender said:


> Great articles lainey! Lots of helpful info to sort things out.
> 
> I am also intrigued by your suggestion to look outside the Cleveland Clinic. Here in Columbus (about 2 hours south of Cleveland), when I was having difficulty with my endo, a few people suggested that there are no good endos in Columbus, and that I ought to go to the Cleveland Clinic. I have no desire to travel that far to see a doc, and was in no shape to drive that far then, but I was considering it. Luckily, I found a good PCP to help manage my thyroid replacement and am pretty happy with her now.


There could be plenty of great endos in the Cleveland Clinic, but based on some of her posts, I'm not very confident that the one that pitseleh is seeing her is of the best quality. I don't know how easy it is to transfer doctors in the hospital, but some clinics, such as Mayo, have very definitive treatment protocols that the doctors stick to and some restrict your ability to switch doctors within the clinic.

People should be bothered when their doctor gives them the brush off, and consider their options. Many people struggle to find a doctor who gives them confidence that they will treat them according to their needs--these of course, are the best physicians, and they are not always found at major hospitals (and also they are...).


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## lavender (Jul 13, 2010)

lainey said:


> There could be plenty of great endos in the Cleveland Clinic, but based on some of her posts, I'm not very confident that the one that pitseleh is seeing her is of the best quality. I don't know how easy it is to transfer doctors in the hospital, but some clinics, such as Mayo, have very definitive treatment protocols that the doctors stick to and some restrict your ability to switch doctors within the clinic.
> 
> People should be bothered when their doctor gives them the brush off, and consider their options. Many people struggle to find a doctor who gives them confidence that they will treat them according to their needs--these of course, are the best physicians, and they are not always found at major hospitals (and also they are...).


I totally agree. I loved my PCP until my thyroid issue hit. Then, I ended up the the ER, and it was clear the doc (from her practice)who treated me there never even read my chart. I started seeing an endo in her office who was terrible, and she refused to do anything that would contradict his lousy treatment. I ended up having to drop the whole practice (which is a really huge network of doctors in my city) because I could not transfer within the office/network of doctors. I had to find someone who believed there was some hope I could feel better, and that I might have some inclination about what I needed.


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