Essential elements of interdisciplinary communication
From a clinical perspective, data that need to be communicated among the disease management team members are acquired in three distinct settings: preoperative evaluations, intraoperative findings, and postoperative data, events, and plans. A wide variety of findings from clinical examination, biochemical testing, cross-sectional and functional imaging tests, and other sources can have a major impact on postoperative risk assessment and therefore may significantly influence decision-making with regard to the role of adjuvant radioiodine ablation therapy (RAI), degree of thyrotropin (TSH) suppression, and extent and frequency of follow-up evaluations. Potentially important preoperative findings that may influence postoperative management include:
- High-risk physical examination findings such as a palpable cervical lymph node, a cervical or upper thoracic scar, fixation or other evidence of gross extrathyroidal extension, hoarseness, stridor, morbid obesity, and dermal metastasis
- High-risk historical features such as prior neck irradiation, unexplained bone pain, suspicion of distant or central nervous system metastasis, current or prior hyperparathyroidism, multiple endocrine neoplasia type 2b, prior difficult intubation, and chronic vitamin D deficiency or other clinical issues that might predispose to postoperative hypocalcemic paresthesias
- Preoperative ultrasound findings with regard to both the thyroid gland and cervical lymph node evaluation
- Preoperative chest radiograph findings, if performed
- Preoperative laryngoscopy findings, if performed
- Known or suspected sites of metastatic disease detected on preoperative imaging
- Performance of any imaging studies using iodinated contrast within the previous 6 months
- Comorbid conditions, including pregnancy, that could influence decisions regarding TSH suppression, thyroid hormone withdrawal, or use of RAI
- Abnormal laboratory values that could influence RAI decision-making such as alterations in renal function or in the complete blood count and differential
Similarly, several kinds of intraoperative information are critical to the risk stratified postoperative management approach. These include:
- Extent of thyroid surgery
- Description of gross extrathyroidal extension
- Completeness of surgical resection (R0, R1, or gross residual disease)
- Details of suspected residual gross or microscopic thyroid tissue
- Extent of lymph node dissection
- Recurrent laryngeal nerve issues
- Parathyroid gland issues
Finally, a number of postoperative findings are also critical to an individualized management approach, including:
- Postoperative hypocalcemia, hypoparathyroidism, vitamin D use, and details of treatment
- Postoperative vocal cord dysfunction
- Other operative complications (such as chyle leak, spinal accessory nerve dysfunction, Horner's syndrome, motor weakness of the arm/shoulder, diaphragmatic paralysis, marginal mandibular nerve deficit) along with the management plan for those complications
- Final pathology report, which optimally should include details supporting extent of thyroidectomy, presence of cancer multifocality, etc.
- Replacement therapy and its timing (levothyroxine, cytomel, calcium)
- Use of iodinated contrast computed tomography in the postoperative period
- Anticipated after-care plan
Operative reporting of thyroidectomy
In addition to documenting the anatomic findings and the surgical care provided during thyroidectomy, the operative report is a tremendously useful communication tool. It should accurately describe the particular thyroid resection using language or data coding that makes the anatomy and the extent of resection clear, along with information sufficient to identify the patient, support the diagnosis and treatment, and promote continuing care. The suggested essential elements are presented here; there are two main methods to convey the variables, necessary data, and anatomy. The traditional way is a surgeon-dictated narrative, while synoptic reporting has more recently come into vogue.
The initial section of a thyroidectomy report should succinctly list the patient's name, medical record number, date of surgery, preoperative diagnosis, postoperative diagnosis, type(s) of anesthetic and any major anesthetic issues that occurred, and names of the surgeon, first assistant, and other surgical participants. The specific indications for thyroidectomy are stated along with the pertinent history and test results and documentation of informed consent. The name of the operation should be clearly stated using precise language; e.g., left thyroid lobectomy and isthmusthectomy, total thyroidectomy with right superior parathyroid autotransplantation, reoperative bilateral thyroidectomy. In two-stage thyroid surgery, reoperative resection of a contralateral lobe is generally termed completion total thyroidectomy with designation of the side removed. A surgical time-out may be described.
For the nonsurgeon readers of a thyroidectomy report, we also recommend use of a synopsis, which is usually placed near the top of the report to describe the pertinent findings as concisely and directly as possible. Information should be recorded promptly because when dictation is delayed beyond 24 hours, operative reports are more likely to contain deficiencies (3). For narrative reporting, although there is some evidence that attending surgeons may be better equipped to dictate complex operations (3), it is also clear that teaching and mentorship during residency demonstrably improves this skill (4,5).
Next, a dictated narrative should briefly describe incision placement, the approach to reach the lobe or gland, any notable detail on the size, shape, extent, and/or consistency of each exposed thyroid lobe, and any intraoperative decisions that were required. The report should clearly indicate if bilateral dissection was performed. The report details should accurately describe the thyroid operation that is named in the operative report. Description should include any identified local invasion, substernal extent, surrounding fibrosis, unusual vascularity, unexpected anatomy, and other notable features, for example, kyphoscoliosis, anomalous right subclavian artery, ectopic thyroid tissue, a long or bifid pyramidal lobe, thyroglossal duct cyst, adherent lymph node, or a nonrecurrent laryngeal nerve. In reoperation, the extent of the thyroid gland, its size and/or shape, and the encountered scar tissue may also be documented. If thyroid tissue is intentionally or unavoidably left behind, the reason, location and an estimated weight or size should be stated. The narrative should describe the identified parathyroid glands, as well as the conduct of parathyroid autotransplantation if required. Identification of the recurrent laryngeal nerve and its branching anatomy is often described, and any unusual or aberrant recurrent laryngeal nerve anatomy is carefully described. The identity and disposition of each resected specimen(s) is clearly given for correlation with the pathology report. The central compartment (level VI) lymph nodes may be described (6) along with specific details of compartment-oriented (central or lateral) nodal resection, if performed. The use and/or results of ancillary procedures are described such as local or regional anesthetic injection, frozen section analysis, or intraoperative parathyroid hormone monitoring. If the technique is used, comment on recurrent laryngeal nerve monitoring should be given (7). Strict brevity is best for descriptions of hemostasis, drain use, closure, dressings, estimated blood loss, and sponge/needle counts. The narrative should conclude with a description of the patient's condition and immediate disposition. Some surgeons also include a hand-drawn sketch or illustration of the operative findings. An example of a short informative narrative report for initial total thyroidectomy is given in Appendix A.
The dictated operative report may be supplemented by an electronic dataset, or a synoptic operative report generated by use of a computer program may supplant it entirely. Synoptic reports are designed to prompt the surgeon to list specific types of operative information in a series of data-populated fields. A web-based synoptic operative report (WebSMR©) for cancer-specific sites including thyroid (8) was recently developed in the province of Alberta, Canada; reports are created through a combination of drop-down menus, yes/no fields, and comment boxes to produce a concise readable note that can be adapted to meet both institutional and individual surgeon needs. The thyroid WebSMR was developed to include prognostic indicators allowing for calculation of the initial stage by MACIS score (9), including specific anatomic details such as nerve and parathyroid gland status. Immediacy and cost-savings in transcription (10) have made the thyroid WebSMR report a provincial standard in Canada, where in the future it is planned to be synced with the synoptic pathology report to provide a concise clinical document for risk stratification (8). An independently designed synoptic thyroidectomy report has also been developed by Memorial Sloan Kettering Cancer Center; it offers particular importance as a research tool and is reported to facilitate systematic documentation based on the concept that thyroid surgery involves a well-defined number of maneuvers or steps required to complete the procedure (11). When possible, we recommend use of a synoptic operative report because it not only offers streamlined ease of use but also proffers the dual advantages of standardized data reporting (8,10–13) and adaptability for the needs of an individual surgeon or program. Some of the data essential for postoperative risk stratification are only available after the operative note is dictated. A suggested basic synoptic report for patients with thyroid cancer appears in Appendix B.
After thyroidectomy: the initial care plan
Regardless of who will be providing immediate care and long-term surveillance for patients with thyroid cancer, communication about the operative course is essential. If all caregivers are using a common electronic medical record, such communication is especially easy to do; an example appears in Appendix C.
Although the management of surgical conditions or complications is often considered the surgeon's responsibility, most multidisciplinary collaborators appreciate knowing the particular or possible complications of thyroidectomy that may bear vigilance. Today there is also an increasing demand to engage the patient in direct perioperative communication. The surgeon's instructions and plan for prophylactic or therapeutic calcium supplementation, wound care, drain management, voice changes, calcitriol use, pending medication changes, pending lab testing including TSH monitoring, return to work, next surgical visit, etc., may be clearly articulated to both the patient and their primary care physicians. In addition, the pathology report is of course a key element in the staging process. For a patient with thyroid cancer on final histology, the letter sent by the surgeon to describe the first postoperative visit can also anticipate the multidisciplinary care plan and the providers involved in care decisions, by providing when possible all available data such as the pathology report and results of molecular marker testing if available.
Particularly in the care of patients with thyroid carcinoma, optimal perioperative communication is a two-way street. Multidisciplinary communication concerning the patient's preoperative conditions and diagnoses, postoperative levothyroxine dosing and any subsequent results of adjuvant radioiodine use, the initial estimates of risks of recurrence and disease specific mortality, and the long-term care plan, is very appropriate and appreciated information for the operating surgeon to receive from nonsurgical caregivers. Interdisciplinary communication also facilitates patient compliance with surveillance.