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When is a Thyroid Nodule Clinic Like a Toyota

When is a Thyroid Nodule Clinic Like a Toyota?

By Julia C. Bonney


Read Consumer Reports and one thing becomes clear: Toyota knows how to build problem-free cars. The company has one of the most rigorous quality assurance programs anywhere in the world. In 2006, Daniel Sudilovsky, MD, chairman of the Department of Pathology at Cayuga Medical Center, published two major papers on research in which he utilized process improvement procedures from Toyota to reduce diagnostic errors and improve thyroid biopsy results at the University of Pittsburgh Medical Center where he was director of Cytology.


Last year, when Dr. Sudilovsky joined the medical staff at Cayuga Medical Center, he teamed up with endocrinologist Adam Law, MD; general surgeon Cory Foster, MD; Jon Cryer, MD, head and neck surgeon; and radiologists Marc Jouandet, MD, and Anthony Massi, MD. With help from Liz Bilinski, RN, and Marguerite Sterling, RN, the group established what might be the first multidisciplinary Thyroid Nodule Clinic in the country. 


Outlining the problem


According to the American Cancer Society about 35,500 new cases of thyroid cancer will be diagnosed in 2007, most of them in women between the ages of twenty and fifty-five years old. The thyroid gland is located in the throat under the Adam’s apple and produces a hormone that is important to many body functions, chief among them the regulation of the body’s metabolism. Nodules (lumps) on the thyroid gland are common and while most of them are benign, about eight percent are cancerous.


Dr. Law explains that the gold standard for diagnosing thyroid nodules is fine needle aspiration (FNA), during which the physician (typically an endocrinologist or a surgeon) inserts a very thin needle into the nodule to withdraw a sample of cells. However, in those instances when the nodule is not easy to palpate (feel with your fingers), the physician will refer the patient to a radiologist for an ultrasound-guided biopsy. After the sample is taken, the cells are then examined under a powerful microscope by a cytopathologist in the Laboratory, who determines if they are cancerous or benign. The cytologist writes a report on his findings, which goes to the referring physician, who shares them with the patient. If the diagnosis requires surgical treatment, the patient makes an appointment to see a surgeon.


While this process sounds straightforward, completing this diagnostic work-up can take weeks. Moreover, even in the finest of our nation’s hospitals, thyroid nodule management has always had quality assurance problems along the way, which is precisely why Dr. Sudilovsky undertook process-improvement research.


“The national data for thyroid nodule biopsy samples showed that 25 percent of the FNA biopsy samples taken were inadequate for interpretation, and 20 percent of the biopsies resulted in false negatives,” explains Dr. Sudilovsky. “The research we did showed that one of the keystones to process improvement was having a thyroid cytopathologist at the bedside or in the ultrasound clinic, giving feedback during the fine needle aspiration. This change dropped the unacceptable percentages of inadequate samples and false negatives from 25 and 20 percent to less than 3 percent.”


The answer to the riddle


A thyroid nodule clinic performs best when all of the experts are on site and the patient can complete the diagnostic phase of treatment in one day, instead of a few weeks. This is precisely what has happened at Cayuga Medical Center. Dr. Foster points out how innovative this approach to care is. “I attended a national conference in May and talked about this with colleagues,” she says. “I met no one who is approaching treatment this way. We’re unique.”


As an endocrinologist, Dr. Law is an expert in the medical management of thyroid problems. He leads the Thyroid Nodule Clinic, which typically meets every other week. “Forming a multidisciplinary committee is the best practice,” he explains. “We have an ethical imperative to do the best procedure possible for our patients, which is fine needle aspiration. Dr. Sudilovsky is an internationally known thyroid cytopathologist. With his added expertise, we are providing solid service, consistently reliable results, and cost-effective, patient-friendly care.”


Patient diagnosis pathway


n  Referral by primary care physician to the biweekly Thyroid Nodule Clinic, located at Cayuga Medical Center Radiation Medicine

n  Examination and assessment by Dr. Law, who performs FNA with Dr. Sudilovsky if the nodule can be palpated

n  If the nodule cannot be easily palpated, the patient goes with Dr. Sudilovsky to the Imaging Department for ultrasound-guided biopsy by a radiologist

n  Dr. Sudilovsky analyzes the sample cells for signs of cancer

n  If cancer cells are not present, the patient goes home

n  If cancer cells are present, the patient sees either Dr. Foster or Dr. Cryer that same day for an in-office surgical consultation.

n  Thyroid surgery at Cayuga Medical Center is scheduled as quickly as possible. If the nodule is not cancerous but is large enough to cause problems swallowing, breathing, or with hoarseness, surgery is scheduled at the convenience of the patient and surgeon.


“Dr. Foster and I have both committed to keeping open appointments in our offices on the day the clinic meets,” explains Dr. Cryer. “After the surgical consultation, we can typically get surgery scheduled at the medical center in one to two weeks. Fortunately, most thyroid cancers are not as aggressive as other cancers, and there is a cure rate of more than 95 percent.”


Dr. Sudilovsky has done more than 5,000 thyroid FNAs. And for twelve years he gave the primary teaching lectures at the University of California at San Francisco and the University of Pittsburgh Medical Center on thyroid cytopathology and FNA to medical residents and fellows in pathology and ENT. “In one visit, we provide our patients with a complete pathological work-up, the diagnosis, and the complete treatment plan before they leave the clinic,” he observes. “We do this minimally invasive approach to care at Cayuga Medical Center as well as any place on the planet.”


“So many diagnoses would benefit from the multidisciplinary team approach,” adds Dr. Foster. “The model we have set up for managing thyroid nodules will be used to initiate other such teams in which experts work together to handle specific problems and streamline patient care.”


Signs and Symptoms of Thyroid Disease

●  Pain in the neck or throat

●  Difficulty swallowing

●  Trouble breathing

●  Hoarseness, voice change, or difficulty speaking

●  Continuing cough not due to cold

●  Swelling of the lymph nodes, particularly in the neck

●  Nodule or lump in the area around the Adam’s apple


(Julia Bonney is a medical writer and writes Cayuga Medical Center’s Health Visions magazine. This article appeared in Fall 2007 Health Visions.)


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