Dialogue between patient and physician concerning the patient’s undisclosed cessation of hypothyroid treatment
| SPEAKER | DIALOGUE | INTERPRETATION |
|---|---|---|
| Julie | Yes, hello? | |
| Physician | Hello Julie, this is Dr Friday. I’d like to talk about the results of your blood test for your thyroid. | |
| Julie | What do you mean? | |
| Physician | I was a bit surprised by the results. Have you been taking your levothyroxine tablets regularly? | |
| Julie | Actually, no; I stopped them a month ago. | By giving this information, Julie is challenging her physician’s opinion. |
| Physician | That’s what I was concerned about when I saw your blood test results—your TSH level is at 18. What happened? | The physician is indirectly criticizing his patient by mentioning his “concerns.” |
| Julie | My OT told me that the pain in my arms might be caused by the drug. I was so sore. I decided to stop taking it to see if the pain would improve. | Julie is justifying her decision by referring to the expertise of another professional—this is a criticism of the physician. |
| Physician | And? | The physician understands the implicit criticism—the occupational therapist recognized the significance of the pain and suggested a solution. |
| Julie | After 3 days, my arms weren’t sore anymore. And I still feel fine, even though I stopped taking the medication. | Julie gives a detail that justifies the other professional’s opinion and that directly opposes the expertise of her physician. |
| Physician | Perhaps, but your thyroid function test indicates that, in this respect, things are not fine at all. | The physician weakly agrees by saying “perhaps,” without explaining the clinical effects of stopping the medication. He continues to directly confront the patient with the laboratory results. |
| Julie | Maybe, but I’ve been feeling so much better now that I don’t have the pain in my arms anymore. And because I’m back in school, I have to write and I can’t have sore arms! | Julie continues her justification by arguing that the unpleasant symptom is gone and that there is even an additional advantage because schoolwork is easier. |
| Physician | How can you be sure that the pain was caused by the levothyroxine? | The physician could take up Julie’s arguments and evaluate them; he instead decides to question and undermine her judgment. |
| Julie | Listen, it took no more than 3 days without it for the pain to go away. | Julie becomes impatient with the physician, who is not acknowledging her personal experience. She justifies her decision by an observation that, in her opinion, is proof of cause and effect. |
| Physician | Have you considered any other explanations? | The physician still refuses to take into account Julie’s argument and suggests there might be other possibilities to then weaken her position. |
| Julie | In my opinion, it’s the only possible explanation. | Julie states her solution. This answer from Julie clearly indicates she does not agree with the physician. |
| Physician | Did you do a test to check, like start taking the medication again to see if the pain came back? | The physician asserts his authority and expertise and challenges Julie by asking her if she acted systematically and scientifically to confirm her hypothesis. |
| Julie | No. I was so relieved not to be in pain anymore! | Julie, without hesitation, admits that she did not check and gives the practical reasons that justify her choice. |
| Physician | The pain was not caused by the levothyroxine in my opinion, and before long, you’ll feel the effects of not treating your hypothyroidism—reduced productivity, constipation, and menstrual irregularities. What’s more, your cholesterol control will also be affected. I thought we had achieved our objective. | The physician uses an authoritative argument by referring to his competency. He explicitly expresses his doubt about the relationship between levothyroxine and arm pain (ie, challenges Julie’s opinion). The physician introduces a threat by giving a list of possible discomforts and ends with a moralizing statement. |
| Julie | Yes, but the arm pain was too uncomfortable; when my OT told me that the levothyroxine could be the cause, I took a chance. | Julie discounts the physician’s argument by citing the intensity of the arm pain as well as the OT’s authority. |
| Physician | I would have preferred that we discussed it before you stopped your levothyroxine. But now, we have a problem. Have you considered taking it again at the start dose, the dose before the increase in February? You were doing well on 0.05 mg daily. | The physician falls back on the criticism that she did not discuss stopping her medication with him. He suggests a solution, which could be a compromise. |
| Julie | I’ll think about it. I have some left. Should I have another test? | Partial acceptance—Julie refuses to compromise. She asks for clarification about the conditions of starting again. |
| Physician | Once you have been taking it again for 6 weeks, you can have another test. Until then, if you feel any of the symptoms of not taking it, please come see me. | The physician gives the conditions and indicates that the interview is at an end. |
| Julie | Thanks, Dr Friday. | Julie ends without committing to restart the medication. |
| Physician | Goodbye, Julie. | The physician signals the end of the conversation without coming to an agreement with Julie. |
OT—occupational therapist; TSH—thyroid-stimulating hormone.