In reference to "Thyroid surgery: changing patterns of practice" and "Emerging trends in the performance of parathyroid surgery".


Dr. Terris and colleagues1,2 have published two thought-provoking studies on trends in the performance of thyroid and parathyroid surgery in the United States. In particular, their most recent paper reveals that graduating otolaryngology residents have, within a decade, caught up to general surgery residents in the per-resident volume of parathyroid surgery logged. Furthermore, Terris et al.1,2 have documented an increasing proportion of parathyroid surgery research being performed by otolaryngologists. This is an innovative study design using resident experience and scientific publications as windows into the world of endocrine surgery. However, these studies only demonstrate a part of the story. There are two important trends, most pronounced in parathyroid surgery, that are only partially reflected in Dr. Terris’s results. First, operative logs in otolaryngology and general surgery residency programs are not analogous. Otolaryngology residents are only permitted to log a case as a surgeon if the resident meets the stringent requirements of performing “greater than 50% of the operation . . . including the key portion(s) of the procedure.” However, general surgery residents need only perform a “substantial portion of the operation.”3 In other words, general surgery residents are able to log some operative experiences as a surgeon that an otolaryngology resident would be mandated to log as an assistant. Accordingly, even if residents in the two specialties log similar numbers of parathyroid operations, otolaryngology residents are likely to be performing more parathyroid surgery. At the same time, however, otolaryngology as a whole lags substantially behind general surgery in terms of academic output in endocrine surgery. Terris et al.’s findings that otolaryngologists account for only 20% of the American scientific authorship on parathyroid surgery only scratches the surface. In fact, if one focuses on high-impact parathyroid research, the overwhelming majority is performed by general surgeons, and this research is published in general surgery journals. A more accurate manner to reflect otolaryngology’s contribution to the field, therefore, would have been to determine an “impact factor” for the work of the two specialties. I obtained a quick, back-of-the-envelope estimate of this by reviewing the bibliographies of the 10 most recent publications on parathyroid surgery on Medline and found that, of 182 unique citations, only 6 (3.3%) were written by otolaryngologists, whereas the remaining 176 cited papers were authored by general surgeons. This April’s annual meeting of the American Association of Endocrine Surgeons, a 300 member organization that excludes otolaryngologists from membership, featured more papers on parathyroid disease than were presented that same weekend at both the American Head and Neck Society and the Triological Society meetings combined. Perhaps because most of the leading academic thyroid-parathyroid surgeons in the United States are general surgeons, no otolaryngology-trained surgeons participated in the development of recent consensus statements on the management of primary hyperparathyroidism sponsored by the National Institutes of Health4 and the American Association of Clinical Endocrinologists.5 There is thus an emerging dichotomy: otolaryngologists’ clinical contributions to endocrine surgery have increased laudably, whereas our research contributions lag. A parallel dichotomy could be said to exist in the realm of facial plastic surgery, in which the clinical volume of otolaryngologist-facial plastic surgeons has grown tremendously, but most high-quality scientific research continues to be performed by general plastic surgeons. Our specialty’s continued strength in the arena of endocrine surgery and our collaborations with endocrinology colleagues require leadership not only in the care of endocrine patients but also in the advancement of the field through scientific research. Dr. Terris and his group are to be congratulated for investigating the very important issue of evolving practices in thyroid and parathyroid surgery. They have elegantly quantified our specialty’s progress, but we still have quite some distance to go.

DOI: 10.1097/MLG.0b013e31814b8ecc

Cite this paper

@article{Morris2008InRT, title={In reference to "Thyroid surgery: changing patterns of practice" and "Emerging trends in the performance of parathyroid surgery".}, author={Luc G T Morris}, journal={The Laryngoscope}, year={2008}, volume={118 1}, pages={189; author reply 190} }