American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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V46N2 SpleenVol. 46, No. 2, 2020 

  • Surgical Anatomy of the Spleen
  • Splenic Injury Diagnosis and Management
  • Surgical Management of Splenic Diseases
  • Miscellaneous Splenic Conditions
  • Splenic Complications
  • The Spleen in Medical History

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Commentary by: Lauren Norell Krumeich, MD, MS; and Rachel R. Kelz, MD, MSCE, MBA, FACS

Citation of Article Reviewed: Kovatch KJ, Reyes-Gastelum D, Sipos JA, et al. Physician confidence in neck ultrasonography for surveillance of differentiated thyroid cancer recurrence [published online ahead of print, 2020 Dec 23]. JAMA Otolaryngol Head Neck Surg. 2020;147(2):166-172. doi:10.1001/jamaoto.2020.4471

Differentiated thyroid cancer is prevalent and survivable, leaving a significant cohort of patients undergoing surveillance for recurrence. Ultrasound is a non-invasive and highly effective surveillance tool for detecting thyroid malignancy in the neck1 that relies on operator skill. Ultrasound is the cornerstone of surveillance for disease recurrence.

In the study, Kovatch et al. explore physician confidence in completing surveillance ultrasounds by performing a cross-sectional study of physicians who treat differentiated thyroid carcinoma and participate in long-term surveillance. A survey instrument was developed using standard techniques based on the past literature and a framework from the study of access to care.2 The study obtains a 69 percent survey response rate and 93 percent cooperation rate, providing a sample of 448 providers. Of these, 320 physicians (71 percent) reported participation in thyroid cancer surveillance and comprise the final analytic cohort. The authors used multivariable logistic regression to examine factors associated with physician confidence in performing ultrasound examinations such as professional experience, practice setting and site, specialty, and a number of thyroid cancer patients evaluated in the last year. One in three physicians queried performed bedside ultrasound. One in five physicians reported high confidence in their ability, and 60 percent reported confidence in their radiologists' abilities to identify suspicious lymph nodes by neck ultrasound. One in three physicians did not report high confidence in either provider group. Factors associated with provider confidence included general surgery specialty compared to endocrinology (odds ratio 5.66) and annual patient volume. The number of years in practice was not associated with confidence. The authors concluded that the lack of confidence in using ultrasound for disease surveillance presents a major obstacle to standardizing long-term surveillance practices in differentiated thyroid cancer.

The study raises an interesting and overlooked question regarding the comfort level of specialists who perform neck ultrasounds with their results and those of local radiologists. Adherence to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines provides a well-designed study and a well-organized manuscript. The response rate for this survey-based study is excellent. Other positive attributes of this study include the diverse physician sample in terms of practices, training, experience, and clinical volume.

Like any thought-provoking study, questions are raised based on the approach, the data presented, and the limitations of the scientific premise. The authors used confidence as a proxy for competence, while it may function as alternative provider attributes. For example, the authors find that confidence is associated with provider specialty in general surgery compared to endocrinology. This finding may reflect the ultrasound-rich training experience in general surgery coupled with additional training for those who complete an endocrine surgery fellowship. Alternatively, this could reflect the ethos of a general surgeon trained to behave as if they are "sometimes wrong but never in doubt." This limitation calls into question the significance of the overall findings.

Beyond the confidence-competence conundrum, the study does not address how provider confidence correlates with actual screening practices. Only 27 percent of the physicians reported performing ultrasonography themselves, and it is not known if the 20 percent of providers with high confidence represent the majority of this 27 percent or another segment of the analytic cohort. Providers reporting lower confidence may compensate by performing more comprehensive examinations in conjunction with experienced radiologists or by relying on alternative imaging techniques.3 Without knowledge of the downstream consequences of these insecurities on guideline adherence, it is difficult to ascertain if the extent of insecurity in ultrasound performance is normal to the practice of thyroid cancer providers or if this insecurity limits cancer care quality.

The authors do not probe potential sources of impaired physician confidence. In addition to an understanding of ultrasound training, data on the annual performance of ultrasounds and the prevalence of thyroid cancer in the treated populations could signify the opportunities for provider skill refinement. The quality of the equipment available for use and data on the adoption of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS)4 is also not provided. Without a clear understanding of the etiology of the provider's insecurities, the proper approach to overcome this potential barrier to guideline adherence remains uncertain.

Finally, the study includes a narrow geographic region with small sample sizes within subcategories. As such, the generalizability and power of the study are limited. It is not clear why these regions were targeted. It is important that the sample includes physicians from discontinuous geographic locations; however, the advantages of these two locales are not reported in the study.

In conclusion, in a diverse set of providers who regularly treat differentiated thyroid cancer, only 20 percent self-report high confidence in their ability to diagnose thyroid cancer recurrence by ultrasound. Only 60 percent feel confident in their radiologists' abilities. Although we cannot ascertain whether confidence correlates with skill and how provider uncertainty informs surveillance techniques, these findings inspire us to reflect on ways to reduce insecurity, whether through training, equipment, or expanded interdisciplinary collaboration.


  1. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133. doi:10.1089/thy.2015.0020
  2. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208-220.
  3. Azadi JR, Hoang JK. Increasing confidence in detecting metastatic thyroid cancer with neck ultrasonography [published online ahead of print, 2020 Dec 23]. JAMA Otolaryngol Head Neck Surg. 2020;10.1001/jamaoto.2020.4604. doi:10.1001/jamaoto.2020.4604
  4. Tessler FN, Middleton WD, Grant EG, et al. ACR thyroid imaging, reporting and data system (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017;14(5):587-595. doi:10.1016/j.jacr.2017.01.046



Recommended Reading

The editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstract on PubMed; free full-text is available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Stassen NA, Bhullar I, Cheng JD, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S294-S300. doi:10.1097/TA.0b013e3182702afc

Article Summary: The guidelines presented here are based on available evidence and expert consensus. They provide useful guidance for management of blunt injury to the spleen.

Gates RL, Price M, Cameron DB, et al. Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review. J Pediatr Surg. 2019;54(8):1519-1526. doi:10.1016/j.jpedsurg.2019.01.012

Article Summary: These guidelines provide useful perspectives on pathways to safe and effective management of solid organ injury in children.