Leaning back in my chair I reckoned myself a cool-headed American president. My right leg was crossed over my left (despite those tight hamstrings), and I began to stroke my chin until a masculine-looking vertical cleft appeared. Was it time for the nuclear option?



The man sitting across the room from me had been waging a war of attrition with his overactive thyroid. There were basically two proposed treatments for his condition - suppressive meds or radioactive destruction of the gland. Each passing year he had pumped more and more medication into his system, hoping that one glorious day his thyroid gland might mercifully surrender. But that day hadn?t come. His T3?s and T4?s, his thyroglobulin, and his antithyroid-receptor antibodies raged on in an ever-widening quagmire of hostility.



Like President Truman on the eve of August 9th I pondered the devastating use of nuclear radiation to bring this battle to a close. In my right hand I held the red pen that could send in the high-flying endocrinology brigade. American endocrinologists seem never to flinch in executing their atomic missions. They are unlike their European, Japanese, and Australian counterparts, who consistently and indefinitely fight the good fight, tirelessly enduring the medication slugfest.* In contrast, American endocrinologists generally go for the jugular. Their eagle eyes target the hyper thyroid. They know that it craves iodine.



They stealthily drop a radioisotope known as Iodine 131 through the blood stream. Millions of unaware thyroid cells continue their busy work, sopping up the nuclear charged I-131. No other cell in the body wants it, but the thyroid still consumes it entirely, exclusively, greedily, and hungrily. It accumulates in the bellies of the cells, emitting local radiation that poisons them to death. The thyroid is thereby rendered harmless, and a Marshall Plan of synthetic thyroid hormone replacement can then be administered in a peaceful and controlled fashion.



What must that first doctor have thought who ordered the nuclear option? Did he pause to think of the collateral damage? Did she righteously want to end the war as quickly and judiciously as possible? Was he at all regretful after the fallout?



In a moment of indecisive hesitation I reiterated the man?s options: he could keep taking the suppressive medications in the hope that his furious thyroid could be held at bay, or he could absolutely ablate the son-of-a-bitch.



?What do you think I should do?? he asked like a torn populace of doves and hawks. ?I mean, what option seems the best??



It was a difficult decision. I didn?t relish the use of power. But the discriminating havoc of I-131 was unlike the wholesale annihilation of the atom bomb. Its thyroid selectivity was a luxury undreamed of in the waning days of World War Two. This modern weaponry could virtually kill only the bad guys.



I pressed the button on my red pen, clicking the ink fountain into writing order, and sent him off to be nuked for the good of humanity. That presidential feeling passed pretty quickly. So did the delusions of grandeur. I decided to go home, warm up that leftover piece of chicken, and watch reruns of The West Wing in my pajamas.





*The difference in treatment preference between American and non-American endocrinologists is alluded to here in the AAFP journal. Photo shared publicly by Charles Kressbach . No disrespect intended for the victims of Hiroshima. As you know, the 60th anniversary of the controversial use of wartime nuclear power was commemorated on August 9th, 2005.