Wednesday, October 30, 2013
On April 30, 2012, Memorial Sloan Kettering thyroid surgeon and then-President of the American Association of Endocrine Surgeons Ashok R. Shaha delivered the following address at the organization’s 33rd annual meeting in Iowa City, Iowa. In his address, Dr. Shaha reflects on, among other things, the ideal qualities of a thyroid surgeon and the implications of new technologies on the practice and training of thyroid surgeons.
There is clearly an increasing incidence of thyroid cancer and approximately 56,000 new patients with thyroid cancer will be seen in the United States. There is a substantial increase in the number of surgical procedures — approximately 100,000 in 2012 alone.
The complications of thyroid surgery can be quite serious, especially postoperative hematoma, airway problems, and permanent hypoparathyroidism. The most crucial part of the training should be the management of difficult thyroid problems — especially the management of advanced thyroid cancer or recurrence, which may become life threatening to the patient.
The management of thyroid cancer has been the domain of general surgeons since the early 19th century; it must be recognized, however, that over the last two decades there has been a considerable paradigm shift in the parent specialty performing thyroid surgery in the United States and to some extent the world over.
In 2010 researchers reported the experience of general surgery residents in thyroid surgery to be 20 surgical procedures. By comparison, otolaryngology residents had the experience of 50 thyroid surgical procedures.
The critical aspect of the treatment of thyroid cancer is management of the patient from A to Z.
The first surgical procedure offers the best chance of curing patients with locally aggressive thyroid cancer. The ideal thyroid surgeon should be directly involved in clinical research, clinical trials, and basic research, and have the ideal goal of being a surgeon-scientist. The ideal thyroid surgeon should be a good surgeon, a good teacher, and a researcher.
The ideal thyroid surgeon:
- Has been appropriately trained
- Can evaluate vocal cords and voice
- Can make treatment decisions regarding radioactive iodine and external radiation therapy
- Can make intraoperative decisions related to extent of thyroidectomy, invasive disease, and neck dissection
- Can manage complications
- Participates in audit and research
- Can take care of the patient from A to Z
- Can provide the best chance of cure by the best first surgical procedure
- Has knowledge of clinical trials and basic research (surgeon/scientist)
- Is a good surgeon, teacher, researcher, and leader
Head and neck fellowships have recently been attracting fewer and fewer general surgeons, and head and neck surgery is now dominated by otolaryngologists. In 1999, the two major head and neck societies in the United States — the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery — merged to form a new society, the American Head and Neck Society (AHNS).
The head and neck fellowships run by the advanced training council became stronger and stronger, and at present there are 29 programs around the country with 41 training positions. In comparison, the endocrine surgical fellowship started in 2005 and the match started in 2007.
At present, there are 19 programs around the country training 22 graduates every year in endocrine surgery. Approximately 30–40 percent of head and neck fellowship training is around thyroid surgery, and the percentage is rising because of the increasing number of thyroid operative procedures. The majority of fellows trained in head and neck surgery are quite familiar with the management of aggressive thyroid cancer.
Thyroid surgery has been performed for a century, but the new millennium has witnessed a variety of new surgical approaches to thyroid surgery. Open thyroidectomy, minimally invasive thyroid surgery, minimally invasive video-assisted thyroid surgery, and extra-cervical approaches have been used, including transaxillary robotic thyroidectomy.
What is the implication of newer technology in the practice of thyroid surgery and training of thyroid surgeons? The principles of oncologic surgery or performing the oncologically sound operation the first time needs to be kept in mind while using these new technologies. It should be the training of a thyroid cancer surgeon, not the training of a surgical procedure. We should not have the technology in search of a procedure.
I would like to promulgate the philosophy of the endocrine surgical family in AAES. The basic foundation of AAES is mutual respect, collegiality, and friendship, training and involvement of the young surgeons in our organization, progress through our differences, and being the friendliest of the societies.
This year, there are more than 100 residents and fellows attending AAES, a major achievement in training of thyroid surgeons. The fellows do carry certain responsibilities, such as work hard, honesty, humility, a great attitude toward work, colleagues, and family, and most importantly they need to consider thyroid surgery a hobby and relish the joy of thyroid surgery. The goal of a well-trained thyroid surgeon should be to develop centers of excellence.
Edited excerpt from: Training of a thyroid surgeon: from scalpel to robot. Surgery 2012;152(6):943-52.