Hi Dr Sonia and Dr Rebecca. As a physician who almost exclusively sees patients just like the one you describe, I have to take exception to parts of your claim that "watch and wait for the TSH and T4 to become frankly abnormal" is a sufficient treatment option for Hashimoto's disease. Patients with significant symptoms while the labs show subclinical hypothyroidism generally have insufficient conversion to T3, or other problems that do not show on the standard lab panel. It's no wonder people seek out alternative providers when we ignore this. They should not have to endure symptoms, sometimes for years, while being offered no treatment options by their physicians. I am presenting at Texmed this year. The topic is Hashimoto's: the diagnosis is just the beginning. I hope to see you there. Best regards, Dana Gibbs MD
Dr. Gibbs, thank you so much for taking the time to write this — and for the work you’re doing with patients who are often feeling unheard and unwell. We truly appreciate the spirit of your comment.
One thing we hope came through in the episode is that we never want patients to feel dismissed, minimized, or told to simply “live with it.” If that’s how our discussion landed for anyone, that matters — and it’s worth clarifying.
In the episode, when we talked about “watch and wait” for subclinical hypothyroidism, we were referencing current guideline-based approaches that recommend monitoring when TSH is mildly elevated and free T4 is normal — particularly in the absence of pregnancy, infertility concerns, goiter, or very high TSH levels. That recommendation comes from multiple major society guidelines (including the American Thyroid Association and AAFP) based on large population-level data showing that many cases normalize over time and that treatment doesn’t consistently improve symptoms in all patients with subclinical labs. The patient mentioned in the episode was offered treatment for symptomatic subclinical hypothyroidism by her previous PCP but had a strong preference to avoid medications and focus on lifestyle changes at that time.
But — and this is important — population data is not the same thing as individual care. Individualized care should be rooted in evidence, curiosity, and partnership. That may look different in different hands. It should involve a conversation about risks, benefits, uncertainty, and goals — not a reflexive dismissal and not a reflexive prescription either.
We also deeply believe there’s room in this conversation for multiple thoughtful physicians who care about patients and are trying to bridge gaps in our system.
We appreciate you engaging with us respectfully, and we hope conversations like this — especially among physicians — are part of how we move forward in a way that supports patients rather than divides care models.
Hi Dr Sonia and Dr Rebecca. As a physician who almost exclusively sees patients just like the one you describe, I have to take exception to parts of your claim that "watch and wait for the TSH and T4 to become frankly abnormal" is a sufficient treatment option for Hashimoto's disease. Patients with significant symptoms while the labs show subclinical hypothyroidism generally have insufficient conversion to T3, or other problems that do not show on the standard lab panel. It's no wonder people seek out alternative providers when we ignore this. They should not have to endure symptoms, sometimes for years, while being offered no treatment options by their physicians. I am presenting at Texmed this year. The topic is Hashimoto's: the diagnosis is just the beginning. I hope to see you there. Best regards, Dana Gibbs MD
Dr. Gibbs, thank you so much for taking the time to write this — and for the work you’re doing with patients who are often feeling unheard and unwell. We truly appreciate the spirit of your comment.
One thing we hope came through in the episode is that we never want patients to feel dismissed, minimized, or told to simply “live with it.” If that’s how our discussion landed for anyone, that matters — and it’s worth clarifying.
In the episode, when we talked about “watch and wait” for subclinical hypothyroidism, we were referencing current guideline-based approaches that recommend monitoring when TSH is mildly elevated and free T4 is normal — particularly in the absence of pregnancy, infertility concerns, goiter, or very high TSH levels. That recommendation comes from multiple major society guidelines (including the American Thyroid Association and AAFP) based on large population-level data showing that many cases normalize over time and that treatment doesn’t consistently improve symptoms in all patients with subclinical labs. The patient mentioned in the episode was offered treatment for symptomatic subclinical hypothyroidism by her previous PCP but had a strong preference to avoid medications and focus on lifestyle changes at that time.
But — and this is important — population data is not the same thing as individual care. Individualized care should be rooted in evidence, curiosity, and partnership. That may look different in different hands. It should involve a conversation about risks, benefits, uncertainty, and goals — not a reflexive dismissal and not a reflexive prescription either.
We also deeply believe there’s room in this conversation for multiple thoughtful physicians who care about patients and are trying to bridge gaps in our system.
We appreciate you engaging with us respectfully, and we hope conversations like this — especially among physicians — are part of how we move forward in a way that supports patients rather than divides care models.
Wishing you a meaningful presentation at TexMed!