Confusing Management of Patients with Thyroid Disorders (by Physicians)
September 3, 2011, in my Saturday clinic in MDH, I had a patient with a thyroid concern. He has a 4-cm nodule on the right lobe of his thyroid gland which was noted 5 months ago. He has seen other doctors before me and he came to me for another opinion.
As has been my practice, whenever a patient come to me for second or nth opinion, I don’t usually ask right away what were the opinions of the previous doctors. As much as possible, I don’t let the opinions of the previous doctors influence my evaluation and what I have to say to the patient and his relatives in terms of diagnosis and my recommendations. It is only after I have given my diagnosis and opinions on medical management that I ask for what the patient has been told by the previous doctors. This is more out of curiosity. Sometimes, I don’t ask anymore and oftentimes, I don’t ask for the names of his previous doctors and their respective advices to avoid any repercussion.
In this particular patient, I did what I usually do for patients coming for a second or nth opinion. After I did my focused interview and physical examination, aided by written explanation and analysis and with the use of drawings and illustrations, I told him chances are he has a colloid adenomatous nodule (a non-cancer thyroid disorder).
Before I took a look at all diagnostic tests that were done on him by the previous doctors, I told him the following:
“If you have thyroid function tests done, I expect them to be normal as you have a thyroid nodule and a normal pulse rate.” [True enough, the results of his thyroid function tests were normal as I predicted.]
“If you have an ultrasound done on your thyroid gland, if the result shows cystic or complex mass, that will support my diagnosis of a colloid adenomatous nodule.” [True enough, the result of the ultrasound showed the term “complex mass.”]
Integrating the results of the diagnostic tests with my clinical evaluation (based on the symptom and sign data that I got from interview and physical examination respectively), I told him that I was 95% sure that his thyroid nodule is a colloid adenomatous nodule.
I then told him the options for further management, diagnosis-wise and treatment-wise. Diagnosis-wise, I recommended a needle evaluation and biopsy. If the result of the needle evaluation and biopsy supports the diagnosis of colloid adenomatous nodule, he has the options of surgical and non-surgical treatment (trial of medical treatment). If the result unfortunately shows something in favor of cancer, then the treatment is surgical or operation.
After hearing my explanations and recommendations, he was quite quick in consenting to a needle evaluation and biopsy which I did in my clinic. The main reason why he was quite quick in accepting my recommendation was because he was afraid of surgery and ALL the doctors he had previously seen, which included endocrinologists and surgeons), recommended SURGERY RIGHT AWAY. He was told by an endocrinologist that there is a high chance that the nodule is CANCER because he is a MALE.
Using a hypodermic needle, I was able to aspirate 3-cc of brown fluid. After aspiration, there was a marked decrease in the size of the thyroid nodule. With these findings and the appearance of the specimen that I smeared on a glass slide which was suggestive of colloid gel, I told the patient I would now increase my degree of certainty to 98% to 99% that the thyroid nodule is a colloid adenomatous nodule. I told him, though, we still have to await the result of the microscopic examination of the specimen (biopsy) for a definitive pretreatment diagnosis.
The patient left my clinic markedly relieved that he has a 98 to 99% chances of NOT having a thyroid cancer and that he has an option for a non-surgical treatment. He said he will be able to enjoy the Lion King play in Singapore on September 11, 2011.
However, before he left my clinic, he made a friendly comment to me: “You doctors are so confusing.”
NOTE1: I am happy to help this patient based on what I think should be done . I am a surgeon but I don’t operate left and right. I operate only when indicated and needed.
NOTE2: This incident, especially, the parting comment of the patient, serves to reinforce the requests of my former students to update my 1986 book on “Thyroid Surgical Diseases.” (See my Facebook Wall: 2nd Edition or 2nd Book on Thyroid Diseases? – August 19, 2011) The main objective of this book was to attempt to clear up confusion in the management of patients with thyroid disorders. In this book, I have a chapter with the title: “Pitfalls in the Management of a Patient with Thyroid Problem.” The circumstances in the management of the patient described above are reflective of what I included as pitfalls in this chapter.