Samuel Gross, a trauma surgeon from the 19th century, had this opinion about thyroid surgery: Horrid Butchery. Thyroid is a very important gland in the lower part of the neck. Several maladies can ail this organ. Some of which, for example, cancer, require surgical treatment. But this gland is enmeshed with blood vessels; there are precarious nerves, large blood vessels, tiny but important glands, and airway in vicinity which make surgery quite tricky. From 19th century's Horrid Butchery, this operation has evolved to quite a safe surgery in trained hands. But risks are still substantial, especially if the operator is not well-versed and surgical safety protocols are not properly followed. Where I trained, we had national pioneers in endocrine surgery, and we endocrinologists felt safe to send our patients for surgery at a relatively low threshold if there was a reasonable indication for surgery. But I have had to leash my natural inclinations for my lack of sufficient knowledge about available expertise and facility for thyroid surgery in Nepal. I remind myself, this was once a Horrid Butchery, until I get a good confidence about our surgeons I will send patients to surgery only as a last resort.
At clinic today, an intern came up to me to discuss a patient that she was seeing. The patient was sent to medical clinic from surgical department to get blood sugars controlled before surgery. This was a 69 year old woman from Saptari. She noticed some pain in the neck nearly 6 months back. When evaluated at Biratnagar, she also got an ultrasound of the neck which showed two small swellings in the thyroid gland. They biopsied these swellings. There was no evidence of cancer. She was given thyroid hormone with an idea that it may help shrink these swellings. But she continued to have some vague pain in the neck and was referred to Kathmandu for further evaluation.
At Kathmandu, she underwent a repeat imaging of the thyroid gland which again showed those same swellings. One was described as complex (had areas of fluids separated by solid tissues) another was less than a centimeter in size. The radiologist, reported it as having a possibility of cancer based on the "complex lesion" and that it needed a biopsy for evaluation. She underwent a biopsy of these swellings: this did not have enough tissue to make a diagnosis. On the repeat biopsy, it was reported as not having any evidence of cancer. But the surgeon who saw the patient was worried about the report of possibility of cancer on imaging studies. So he decided to have patient undergo surgery. She was admitted to the hospital. But her blood sugars were out of control. Surgeons hesitate to operate when blood sugars are high because it increases the risk of wound complications. They consulted medical team. Medical team started her on insulin but blood sugars were still not controlled and surgery was cancelled. She was transferred to medical ward for blood sugar control and after a few days, since her sugars were still not controlled, discharged home with instructions to follow-up at OPD to adjust insulin dose gradually.
Having been trained in the problems of thyroid, I looked at each of these investigations. The description of the "complex nodule" and also the printed pictures of the nodule was something called "spongiform nodule." For the size of the nodule that the patient had, it is recommended not even to biopsy spongiform nodules because the risk of this being cancer is very low (99.7% of these nodules are not cancers). So the radiologist had over-called the finding. The surgeon relied on a misleading interpretation. By this time, the patient had spent several days away from home in Kathmandu, many of those in hospital bed, scared she had a neck cancer, ready to have neck slit open, forget about the rupees than vanquished in this anguish.
So what do I tell her?
I explained to her what I thought of her problems and investigations so far and that her chances of having cancer is extremely low. I told her, if I were her or she was my mother, I would not have the surgery. She looked very relieved by this conversation. But she did ask, "Why did I have to go through all of this?"
I do not know. I can not put blame on any one person. Radiologist over-called it, but it was not a mistake. They try to be safe than sorry. You do not want to miss a cancer but in this process you have some false positives. Surgeon was also not wrong to plan to take out the gland for a concerning radiology report. But what patient went through was a real hassle and a real risk.
For me, this has been a lesson. A lesson in the backdrop of the debate on specialization. There is a rigorous debate about patient outcomes and specialty care. Studies are divided, some studies show patient outcomes are better with specialist care. Others show equally good or better, yet cost-effective care by generalists. So there are believers in specialist care and proponents of generalist care. Although I am a specialist, I have had warm feelings for generalist care. Especially in the context of resource poor Nepal. That is one of the reason I have been doing more of internal medicine at this public hospital, than my specialty of endocrinology. Besides, our public healthcare systems are so rudimentary and rooted in crisis mode (doing patch work for crises that come along) it just does not seem conducive for specialty care.
However, with the event like above, it seems to me that specialist care will be profoundly important for Nepal. What this patient went through was a totally unnecessary hassle with an incredibly high risk. It could have been prevented if a trained endocrinologist had at one time evaluated the patient. It is not the same Nepal, from 8 years ago when we finished our medical schools. At 4000 rupees you can now get a CT scan and it seems like there are more Nepalis now who find paying few thousands of rupees not a very big deal. Multinational laboratory chains have made it possible to get any lab test you want done for few extra bucks. The volume of investigations patients go through is astounding. Perhaps done unnecessarily many a times, driven by profit motives, in many of these for-profit institutions and private practices where they get financial remuneration for ordering lab works. Accordingly, complexity of information available on the patient's illnesses and lab findings is growing massively. This gives an opening for misinterpretation of these lab and investigations results. There has to be someone who can focus on specific areas and build expertise to interpret these complex results.
Study data on specialists vs. generalists may be one thing, but when I think about this patient, and ask myself, instead of me if any other endocrinologist had seen this patient, would they have prevented this hassle and risk? The answer is a solid yes. These are basic stuff in our training.
There must be several other patients who are getting their sugars controlled right now. They will undergo a Horrid Butchery with splendid sugar levels. Knowing that these patients did indeed need surgery would be nice. Wouldn't it?
At clinic today, an intern came up to me to discuss a patient that she was seeing. The patient was sent to medical clinic from surgical department to get blood sugars controlled before surgery. This was a 69 year old woman from Saptari. She noticed some pain in the neck nearly 6 months back. When evaluated at Biratnagar, she also got an ultrasound of the neck which showed two small swellings in the thyroid gland. They biopsied these swellings. There was no evidence of cancer. She was given thyroid hormone with an idea that it may help shrink these swellings. But she continued to have some vague pain in the neck and was referred to Kathmandu for further evaluation.
At Kathmandu, she underwent a repeat imaging of the thyroid gland which again showed those same swellings. One was described as complex (had areas of fluids separated by solid tissues) another was less than a centimeter in size. The radiologist, reported it as having a possibility of cancer based on the "complex lesion" and that it needed a biopsy for evaluation. She underwent a biopsy of these swellings: this did not have enough tissue to make a diagnosis. On the repeat biopsy, it was reported as not having any evidence of cancer. But the surgeon who saw the patient was worried about the report of possibility of cancer on imaging studies. So he decided to have patient undergo surgery. She was admitted to the hospital. But her blood sugars were out of control. Surgeons hesitate to operate when blood sugars are high because it increases the risk of wound complications. They consulted medical team. Medical team started her on insulin but blood sugars were still not controlled and surgery was cancelled. She was transferred to medical ward for blood sugar control and after a few days, since her sugars were still not controlled, discharged home with instructions to follow-up at OPD to adjust insulin dose gradually.
Having been trained in the problems of thyroid, I looked at each of these investigations. The description of the "complex nodule" and also the printed pictures of the nodule was something called "spongiform nodule." For the size of the nodule that the patient had, it is recommended not even to biopsy spongiform nodules because the risk of this being cancer is very low (99.7% of these nodules are not cancers). So the radiologist had over-called the finding. The surgeon relied on a misleading interpretation. By this time, the patient had spent several days away from home in Kathmandu, many of those in hospital bed, scared she had a neck cancer, ready to have neck slit open, forget about the rupees than vanquished in this anguish.
So what do I tell her?
I explained to her what I thought of her problems and investigations so far and that her chances of having cancer is extremely low. I told her, if I were her or she was my mother, I would not have the surgery. She looked very relieved by this conversation. But she did ask, "Why did I have to go through all of this?"
I do not know. I can not put blame on any one person. Radiologist over-called it, but it was not a mistake. They try to be safe than sorry. You do not want to miss a cancer but in this process you have some false positives. Surgeon was also not wrong to plan to take out the gland for a concerning radiology report. But what patient went through was a real hassle and a real risk.
For me, this has been a lesson. A lesson in the backdrop of the debate on specialization. There is a rigorous debate about patient outcomes and specialty care. Studies are divided, some studies show patient outcomes are better with specialist care. Others show equally good or better, yet cost-effective care by generalists. So there are believers in specialist care and proponents of generalist care. Although I am a specialist, I have had warm feelings for generalist care. Especially in the context of resource poor Nepal. That is one of the reason I have been doing more of internal medicine at this public hospital, than my specialty of endocrinology. Besides, our public healthcare systems are so rudimentary and rooted in crisis mode (doing patch work for crises that come along) it just does not seem conducive for specialty care.
However, with the event like above, it seems to me that specialist care will be profoundly important for Nepal. What this patient went through was a totally unnecessary hassle with an incredibly high risk. It could have been prevented if a trained endocrinologist had at one time evaluated the patient. It is not the same Nepal, from 8 years ago when we finished our medical schools. At 4000 rupees you can now get a CT scan and it seems like there are more Nepalis now who find paying few thousands of rupees not a very big deal. Multinational laboratory chains have made it possible to get any lab test you want done for few extra bucks. The volume of investigations patients go through is astounding. Perhaps done unnecessarily many a times, driven by profit motives, in many of these for-profit institutions and private practices where they get financial remuneration for ordering lab works. Accordingly, complexity of information available on the patient's illnesses and lab findings is growing massively. This gives an opening for misinterpretation of these lab and investigations results. There has to be someone who can focus on specific areas and build expertise to interpret these complex results.
Study data on specialists vs. generalists may be one thing, but when I think about this patient, and ask myself, instead of me if any other endocrinologist had seen this patient, would they have prevented this hassle and risk? The answer is a solid yes. These are basic stuff in our training.
There must be several other patients who are getting their sugars controlled right now. They will undergo a Horrid Butchery with splendid sugar levels. Knowing that these patients did indeed need surgery would be nice. Wouldn't it?
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