Underactive thyroid is a common condition. The thyroid gland sits in front of the trachea (windpipe) and can be felt as a slightly squishy protrusion just below the larynx (voice box). It is important in regulating the body’s use of energy.

In general, underactive thyroid is easily treated with thyroid hormone medication, which replaces what the thyroid gland is no longer producing. But for one of my patients, it wasn’t going according to plan.

We were on our third thyroid medication adjustment, and the patient’s thyroid blood level still had not budged any closer to normal. This struck me as unusual, and inspired some further inquiry.

“Are you taking the thyroid medicine as directed? Ever forget to take it?” I asked. I reviewed my instructions that he should take it once daily in the morning, ideally before breakfast.

“I follow the instructions exactly,” he replied without hesitation.

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At this point in the conversation, I would usually move on from questions about adherence to medication instructions. Perhaps it was something about this patient’s unwavering confidence that led me to carry on a bit further.

“Tell me more about how you take the medication every day, and the way you work it into your daily routine,” I continued.

His response was very revealing.


“I take the thyroid medicine in the morning on an empty stomach, a half hour before breakfast,” he began. “Sometimes I forget and eat breakfast first, so I cannot take the pill.”

“So, if you eat breakfast first, you skip the dose that day?”

“Yes,” he said, “I assume the medicine does not work if you eat first.”

“Hmm … How often does that happen?”

“About three times a week, I’d say.”

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I was stunned and fascinated. As he accurately stated, he did follow the medicine’s instructions. That meant he was missing three doses per week, but did not view this as a problem, thinking the medicine would not work at all if he ate breakfast before taking it.

I explained that, in fact, the medicine would work, but would not be absorbed as efficiently if taken with food. However, taking it with food is better than not taking it at all.

He began taking it every day, and in a few weeks, his thyroid blood levels were perfect on his current dosage.

Clinicians may assume that our patients understand and will remember instructions given during office visits. In fact, studies have shown that recall of medication instructions is often much worse than we think; this is the case in patients with all backgrounds and educational levels. It was also a reminder for me that patients may interpret instructions too literally, and assume that it is better to skip a dose than to allow an imperfection, such as having breakfast first.

One helpful solution is a technique called “teach-back.” In this method, the clinician asks the patient to repeat, or “teach back” the medication instruction which they heard. It goes something like this:

“Just so I am sure that I was clear, please explain to me how you will take your new medicine, as if you are the doctor and I am your patient.” Here an opportunity to correct misunderstanding may be revealed.

If your clinician does not go through a “teach-back,” you can initiate it yourself.

“Doctor, do you mind if I try to explain those instructions to you, just to be sure I got it right?”

This is a wonderful way to be your own health care advocate, and avoid problems like this mystery case illustrates.

Jeffrey Millstein is a primary-care physician and medical director for patient experience-regional practices at Penn Medicine.