What’s The Deal With Thyroid Nodules? (w/Dr. Patrick Ha)

Dr. Z: Hey guys, Dr. Z, welcome to “The ZDoggMD Show”. Today I have a returning guest. He was in the neighborhood. I thought we would talk about important stuff. This is Dr. Patrick Ha, he’s a UCSF professor and wait, what are you again?

Dr. Ha: I am the chief of head and neck surgical oncology.

Dr. Z:  See, he told me like five times and I’m like, I’m gonna flub that because I’ll say head and neck chief of oncological surgical.

Dr. Ha: It is complicated.

Dr. Z: Everything’s complicated these days, man.

Dr. Ha: Sure is.

Dr. Z: How how’s life been for you? Welcome back by the way to the show.

Dr. Ha: Yeah, of course. Good to see you again.

Dr. Z: The reason I love having you on is that more about head and neck cancer prevention treatment, and just oncology in general than most people I have ever met, and we happened to go back a long way. So the other couple shows we’ve done really, really got people woken up to this idea of HPV as a cause of head and neck cancer, a preventable cause so you can actually vaccinate against it.

Dr. Ha: Crazy, yeah.

Dr. Z: Yeah. And what do you think’s been going on recently with, because of pandemic vaccination rates. Do you think this is gonna impact head and neck cancer coming down the line?

Dr. Ha: It’s hard to say. I mean, I think that the uptake of HPV vaccine in particular is still, it’s pretty flat.

Dr. Z: Hasn’t changed much.

Dr. Ha: Hasn’t changed too much as far as I can tell, but I think that actually they just gave an indication now for head and neck cancer as one of the things that actually can be prevented as a result of it.

Dr. Z: Oh, really? Like an FDA indication fright.

Dr. Ha: That’s right. Yeah. So that was kind of big news to us. I mean, we were sort of telling people this, but it’s nice that it’s official. I don’t know if that’s enough to move the needle that people are suddenly stimulated to go vaccinate, but at least it sort of validates it as a potential curative vaccine.

Dr. Z: Yeah, and for people who don’t know, I mean, HPV can be the cause of multiple head and neck cancers and so the vaccination for HPV, that’s typically given to boys and girls, somewhere around 11 years old and before they’re exposed naturally to HPV can potentially prevent these head and neck cancer.

Dr. Ha: Yeah.

Dr. Z: And you’re seeing an increase in incidents in HPV related cases.

Dr. Ha: Yeah, that’s right. So for, at least in the US, the incidence of smoking and things like that, is generally going down. So a lot of the other sub sites, like say in the mouth or the voice box those sorts of things, that the number of patients coming in each year is going down, which is great. But the one subside that is rising is the oropharynx or the tonsil, or base of tongue, and that’s solely due to HPV. So we’re hopeful that, in another 10, 20 years that people are vaccinating even a little bit, it’ll start to bend that curve back down and, we can help sort of her not eradicate it, but at least get it back down to kind of acceptable levels.

Dr. Z: So what happened to Eddie van Halen?

Dr. Ha: That’s a good question.

Dr. Z: Yeah.

Dr. Ha: Truthfully, I haven’t read that much about it, but I have seen some quotes and I know that he had oral cancer. So this is in the tongue non HPV related. So in the tongue, it’s mostly, most of the times due to smoking and drinking. Those two in combination are particularly bad for this. So I know that I just read quotes that he blamed this metal pig that he would hold in his mouth and people have done things like thought it was due to dental fillings and things like that. So, there’s all kinds of theories and they are sort of interesting and that it usually does happen on the side of the tongue. So there is maybe something to this, like friction or, the cells have to turn over more often. So maybe they’re, have a higher chance of something going wrong and then turning into a cancer. But it doesn’t show me that that’s causative.

Dr. Ha: Right.

Dr. Ha: Right. So just because it happens there, it doesn’t mean that it was because of the friction versus, other things like smoking or alcohol.

Dr. Z: So Eddie, I went back and watched a bunch of his videos after he passed, because he’s one of our, as a guitarist hero. I mean, he’s a God. and I’m watching him back in the 90s and 80s, even with Sammy Hagar where he does this prolonged eruption solo, if you can see this on YouTube, it’s really amazing. So he’s got a cigarette in his mouth, he’s got the pick in his mouth, he’s got a thing of beer, he’s doing all these things while blazing the solo And this is year after year after show after show after show. So, like you said, correlation versus causation, like how much of it is the pic, how much of it is the amazing exposure to alcohol and tobacco?

Dr. Ha: Yeah, and I think that it’s not so much like a judgment on his character or anything like that.

Dr. Z: Right.

Dr. Ha: It’s more so just, it’s really just to highlight that look, if smoking does cause cancer, it will cause cancer in the mouth, it’ll cause cancer elsewhere. So I think it’s important just to not try to hide that, but it’s tracks term, nothing of who he is and like how amazing of a guitarist he was. But for some reason that gets, it gets sort of caught up in the media or something like it.

Dr. Z: Yeah.

Dr. Ha: I’ve seen the quotes many times and I think, ah, that’s not, it’s probably not exactly the whole story.

Dr. Z: Yeah. And there may be a little bit of denial too in the part.

Dr. Ha: Yeah.

Dr. Z: Yeah. Now what you said is important because I think like, especially dealing with cancer, people’s first question, when I had Marty Macquarie on the show is a pancreatic surgeon and deals with a lot of pancreatic cancer, the first question patients ask is, why did I get this?

Dr. Ha: Yeah.

Dr. Z: Right.

Dr. Ha: No, it’s a common question. And I think, I don’t know my approach to that when I talk to patients is more so that if there are things that you’re doing that might trigger it or make it worse or somehow make the recovery or the treatment more difficult then we needed to address those things.

Dr. Z: Right.

Dr. Ha: But in many cases, we don’t know why. So there is a group of patients who never smoked, never drank, are gonna to get cancer of some kind. We see it in the tongue as well. And in particular tends to be young women. And there’s a group of these patients who were like in the thirties or even twenties who developed tongue cancer that never smoked, never drank. They’re kind of young for any exposure history anyway, is not HPVDr. Ha: related we don’t really understand why, but if you look at the genetics of it, meaning that the DNA and kind of what’s going on in these cells, is kind of the same as a cancer that erupted in someone who had been smoking all their lives. So it’s the same kind of DNA mutations and things.

Dr. Z: Huh? Are they the children of smokers?

Dr. Ha: No.

Dr. Z: No.

Dr. Ha: Yeah, so there’s, again, so people tend to think, oh, but my dad smoked or I worked in this company and our breaks or someone next to me, he was smoking, but you really pinpoint anything. And so there are times when, like this whole frictional idea that, oh, the cells are just turning over and something bad happens and it gets carried through and then another bad thing happens, when a few more bad things happen, then all of a sudden it becomes a cancer. So again, like it doesn’t sort of change what we do, but it, I think people like to have some sort of meaning behind it. I mean, that’s not always the case.

Dr. Z:  And that meaning, cause you brought this up actually, the meaning can be conflated with a moral finger-pointing, which I think is very harmful, right.

Dr. Ha: Yeah, I agree. I think that, again, we’re not trying to judge, the same way that someone is smoking and they don’t have cancer. I’ll talk to them about smoking cessation and trying to prevent it things from happening down the road, but it’s not that I’m judging them.

Dr. Z: Right.

Dr. Ha: It’s more so that, hey, I just want you to make aware and there are things we can do. So with cancer, I think this is also where HPV does become a little bit interesting is that, it’s a sexually transmitted disease. Some people kind of look at their partners, I think about kind of what they’ve done and, maybe they talk about it, maybe they don’t, but there is sort of an underpinning of judgment, denial, and sort of, what’s the word, kind of like meaning of why did I get this cancer? Like there must be something deeper behind it as opposed to at random.

Dr. Z: Yeah, yeah and, and humans are sort of meaning seeking creatures. They’re machines that seek meaning.

Dr. Ha: Especially for this, ’cause it’s such a life altering event and life altering diagnosis.

Dr. Z: Right.

Dr. Ha: So I think it’s normal. I think it’s natural for people to think that.

Dr. Z: Right.

Dr. Ha: But you don’t want it to get in the way of treatment.

Dr. Z: Right. And speaking of which, so what if someone decides they’re gonna continue to smoke. They have a smoking related head and neck cancer and they continue to smoke during treatment. How do you sort of talk about that with your patients? Think about that.

Dr. Ha: Well, again, so approach them in a nonjudgmental way and just indicate that, look, a lot of these cancers are due to smoking, and we know that it’s addictive. So we do have programs in place where we actually have sort of like professional full time smoking cessation counselors and specialists, so we can refer them to them. But that implies that they have some will to quit and some desire.

Dr. Z: Right.

Dr. Ha: I will say that with a cancer diagnosis, it’s a pretty strong put in the pants to go, hey, something that something’s going on here and it’s not good.

Dr. Z: Yeah.

Dr. Ha: And then I will say that for head and neck cancer is usually the treatment is somewhat rigorous. So at some point they stop smoking because it’s just, it’s uncomfortable, and it hurts or.

Dr. Z: Too much.

Dr. Ha: And the questions are gonna start again. So that’s where we have an opportunity as well, to try to get them on medications counseling so that, like, look, you did it. The cancer’s gone, you stopped smoking for this few months period, why don’t we keep it going? So that’s kind of a little golden window there.

Dr. Z:  And this, again, we’ve spoken about this before, but this idea of the interdisciplinary team that you have, right. You’re not the boss of everybody. This is a organism that you’ve created that.

Dr. Ha: Yeah, for sure.

Dr. Z:  Yeah.

Dr. Ha: Yeah, so we integrated them quite a while ago actually and we have some grants sort of centered on, how can we implement this and track it better. But, I think that it starts with everyone on the same page. So they know that this is what happened we just say it in a matter of fact way that this is one of the reasons for it that we can help you with it. And that I tell him, I realized you’re not interested now or whatever the thing may be, but then I’m gonna keep bugging them every visit. And so I say that from the beginning so that they know that I’m not judging them, it’s just part of the thing.

Dr. Ha: Hey.

Dr. Ha: It’s like taking a vital sign. Like, hey, you still smoke on how much and you sort of approach it in a way that doesn’t make them feel threatened, but you sort of have to partner with them and say, look, let’s try to do this together.

Dr. Z: Do you think during the pandemic, people have been not coming in. What have you seen in your practice.

Dr. Ha: Yeah, let’s go crush it so. We deal with a very highly specialized group of patients, right? So if you have a tongue cancer, something grown out of your throat, big neck mass, generally speaking, most people are gonna come in for that. So during the pandemic, we probably, we’re about 80% of our typical practice basically. And then it’s definitely increased since things have been testing and people are comfortable getting out there. And what we looked at our data it actually showed that the patients with more advanced disease were coming in.

Dr. Z: They were coming in.

Dr. Ha: Yeah.

Dr. Z: So they weren’t holding off.

Dr. Ha: No, although it’s funny. We ran one citizens look at how far away do they travel from so.

Dr. Z:  Yeah.

Dr. Ha: UCSF, it’s a pretty wide area of patient.

Dr. Z: It’s a magnet hospital.

Dr. Ha: Yeah.

Dr. Z: Tertiary referral.

Dr. Ha: And so if we look at the month prior, or the year prior month to month, the average distance was like about 120 miles. And then since the pandemic, during that time and during March and April and things were particularly bad and shut down, that average distance was about 50 miles.

Dr. Z: Oh, so the catchment area dropped again.

Dr. Ha: And I think probably what happened was is that if people are in an underserved area or a place where our healthcare is just defacto kind of hard to get to they don’t have access. If a few practitioners say, look, we gotta shut down, it’s too dangerous, then they’re not able to get seen to get that referral. And they want us to know where to go, they know what to do.

Dr. Z: So the feeder docs were shut down.

Dr. Ha: Yeah.

Dr. Z:  Oh. That’s interesting and that raises the question of, have you seen big ethnic and socioeconomic disparities in head and neck cancer outcomes and treatments and even diagnosis?

Dr. Ha: Yeah, that’s a tough question because that’s obviously a bit of a catch word and the thing is, is that it’s not necessarily that there’s much of a biological difference, right, between a cancer between the different ethnic groups. There can be some minor variations, but generally speaking, we don’t tailor treatment based on ethnic background or even think of it that way. But I think access to care may be an issue, so it’s a bit of a socioeconomic thing, but definitely, here in California and there’s, that the distance factor that if you live within the Bay area, you tend to have better access to healthcare. There’s more doctors and, you have better insurance maybe, and that sort thing, but then you go out about three or four hours, then it starts to become tougher for people to see a doctor

Dr. Z: Yeah.

Dr. Ha: Or even have the wherewithal to know where do I go for this problem? I’m not sure what to do.

Dr. Z:  Right, right, right. And the absence of good primary care as a being able to tie it together as felt quite profoundly.

Dr. Ha: Right.

Dr. Ha: So we did some video visits during this time and we, we used it almost as a triage, but, we do need to examine people so it’s kind of hard for us to maintain a video relationship with a patient with a potential head, neck cancer.

Dr. Ha: But I even had some practitioners where the patients couldn’t do ZOOM, ’cause they don’t have a smartphone or didn’t know how. They would go to their office and zoom in with me, from the physician’s office.

Dr. Z: From the physician’s office.

Dr. Ha: Yeah and I was like, how dedicated are these people? And they would sit there with a nurse and kind of help them through it.

Dr. Z: Yeah.

Dr. Ha: And that was really heartwarming to see that.

Dr. Z: That’s great, yeah.

Dr. Ha: But not everyone has that.

Dr. Z: Right, right, right.

Dr. Ha: Person, you know?

Dr. Z: Right, and what you said about needing to examine patients, I mean, I’m still a teleDr. Ha: health skeptic, on the level that I think, yes, I think there’s a couple problems. One is you need a relationship ideally with the person you’re telehealth thing with. I think that helps, right, especially if you’re talking primary care specialty, I get it.

Dr. Ha: Yeah.

Dr. Z: But the second thing is touching patients and actually examining them and you bring that up as a head and neck obstacle, right because you need to look in there.

Dr. Ha: Yeah. And I think for what we do, it’s even more invasive right there in dark areas. It’s not like on the skin where you can try to show you my mole or what do you think about this? But yeah, so I do think that teleDr. Ha: health was important for, like I said, triage and screening, and then what it did do, it meant that the in person visit could be a little more efficient and faster.

Dr. Z:  Oh yeah, ’cause you

Dr. Ha: Maybe you’re not spending as much time in the room with you or kind of theory with other patients. But it also then, I will say that when you meet the patient, you feel like you kind of know them. So there’s that aspect of, that the video it’s more than a phone call.

Dr. Z: Yeah.

Dr. Ha: There’s a face, you kind of start to develop that relationship.

Dr. Z:  Okay, that’s interesting ’cause people don’t talk about that that much, that you’ve actually done the groundwork in a way that a phone call wouldn’t do.

Dr. Ha: You could do with a phone call, but I think maybe just people’s attention aren’t as centered. And I will even say this is that when you do a video visit with a patient, you’re trying to go through all the data and discuss with him, I don’t know, there’s a mini study on this, but they tend to be faster.

Dr. Z: Interesting, than a phone?

Dr. Ha: Than an in person.

Dr. Z: Than an in person.

Dr. Ha: Cause I think what it is is either that they, because that interface it artificially sets a barrier.

Dr. Z:  They’re focused.

Dr. Ha: Or that, yeah, I don’t know what it is. I can’t explain it but I’ll say that, during the pandemic we had scheduled slots for new patients on video, and we might schedule a 45 minutes or whatever the number was. But then you’d look at me like, oh, in 25 we’re done. Maybe, ’cause we’re not examining them. But also that I think we felt like, okay, we’re setting up the stage for the in person visit if need be, or we can say, hey, I’m comfortable with you coming in a few months ’cause it doesn’t look to be that bad according to the data I have.

Dr. Z: Got it.

Dr. Ha: But, but it is fairly efficient.

Dr. Z: Yeah. And you’re probably not spending so much time on sort of social pleasantries and stuff.

Dr. Ha: Yeah, So that’s a downside, right they’re. You’re not getting to know them as well or maybe all their questions aren’t quite answered ’cause they’re sitting there in front of you and they’re like, oh I have his time now.

Dr. Z: Yeah.

Dr. Ha: But for better or worse, I thought it has a place, and I think it just different specialties, different groups have to figure out how they wanna use it.

Dr. Z: So one thing and we talk about screening and access and all that. The thing that drives a lot of people crazy, and we were talking a little bit offline about this is thyroid stuff. Thyroid nodules, I mean, we won’t even get into like actual replacement ’cause that’s more of the endocrinologist like, oh, armor thyroid and this and that and the high Graves’ and Hashimoto’s, okay that’s another talk. But this we’re talking about people who discover either by palpating, by ultrasound, incidentally, thyroid nodules, and what do you do about them? And so help help me understand. Teach me about these.

Dr. Ha: Yeah, sure. So, it’s a broad topic, a lot of different angles, but it’s really common. So I think there’s been a number of studies looking at what percent of people have a thyroid nodule. So I think we should use that word carefully nodule, not sort of cancer. So those are, those are different things. But the thyroid nodule’s common. So, and particularly in women, but probably by the age of 50 to 70, there’s probably about half or two thirds of people have some sort of thyroid nodule if you were to check.

Dr. Z: That’s a lot.

Dr. Ha: It’s a lot, right? So it comes up a lot on, spine MRIs or, they get a CT cause they had a car accident and then they go, there’s a thyroid nodule and go get that checked out. So there’s some incidental ones. There are times when, now that there’s more awareness maybe a thyroid that certain primary care doctors will look and feel and kind of pay more attention, as opposed to the patient coming and saying, what’s this big thing here, but they’re kind of looking for it. Sending more ultrasounds, a lot of inDr. Ha: office ultrasounds at this point. So we’re finding them for sure. And then what it means is that you’ll find more that are cancers.

Dr. Z: Right, just by simple numbers cause you’re screening. Or something else.

Dr. Ha: So I think the is is that what’s interesting, interesting quotations about thyroid cancer is that it can be pretty indolent. So pretty slow growing. There’ve been some autopsy studies saying that there are many people who die with thyroid cancer. That wasn’t their cause of death.

Dr. Z: Oh so kinda like prostate, like yeah, it’s there, it doesn’t kill you.

Dr. Ha: It’s just hanging out. They never knew, they never had that diagnosis tag them.

Dr. Z: Right.

Dr. Ha: And so then the precursor to that is thyroid nodules. And so some percentage of those are gonna be cancerous. So what we’re dealing with now is trying to figure out what to do with that and I think some of it is because of technology. So definitely the fact that we have ultrasounds, that people are more aware, we’re finding them and so when you look at the history of the cancers, how big are they? They’re smaller now than historically. So, we’re seeing them in ultrasounds in the office and in these incidental tests. And so the incidence of thyroid cancer is definitely rising, but the incidence of big thyroid cancers is about the same. The number of people who pass away from thyroid cancer, at least in the US per year has been flat for decades.

Dr. Z: Oh man, okay there’s a lot here. Let me see if I can unpack some of this and process it with you and you can teach me about this because what that tells me is potentially we’re over screening, not over screening, but in the sense that, because we’re screening so much, we’re finding disease that we never found before, but our actual outcomes aren’t changing because the disease that actually matters we would have found eventually anyways, cause it would have presented.

Dr. Ha: Correct. And so that sort of goes to like screening in general.

Dr. Z:  Exactly, that’s the bigger picture. And this is where you get like the COVID deniers come out and they’re like, but if we just didn’t test, then there wouldn’t be so many cases, right. But the difference there is that you’ve got an infectivity issue, so you wanna actually.

Dr. Ha: You could transmit it, right.

Dr. Z: That’s right.

Dr. Ha: So there’s a difference.

Dr. Z:  You’re not gonna transmit a thyroid nodule.

Dr. Ha: No.

Dr. Z: We don’t think.

Dr. Ha: No.

Dr. Z: Yeah.

Dr. Ha: No, no virus.

Dr. Z: Right.

Dr. Ha: So yeah. So it’s, what has meant though is that there’s an interesting shift at least within the surgical community where before if we saw a thyroid cancer diagnosis it meant, okay, we take out the whole thyroid and it was like, that’s it.

Dr. Z:  Done.

Dr. Ha: Yeah done. You don’t think about it.

Dr. Z: For the rest of your life.

Dr. Ha: Replacement, there’s a little risk of the surgery, but it’s acceptable because they have thyroid cancer, it’s cancer. And it was easy to tell patients that cause they’re like, Oh, I have cancer. Do what you gotta do.

Dr. Z:  Exactly.

Dr. Ha: That’s kind of the mindset of most people.

Dr. Z: Right.

Dr. Ha: It’s also a, typically a younger, healthier group of people who developed this cancer probably in their 40s and 50s is not uncommon.

Dr. Z: Right.

Dr. Ha: So, you know what happened though is then all these statistics started coming out that, okay, death rate, same, not rate, but even the number of deaths is low so the rate was actually going down because we’re diagnosing more that we’re finding smaller and smaller cancers. So now we sort of pivoted to being a little bit more conservative about surgery and a lot of it really depends on the pre diagnostics and workup. So getting the ultrasounds and not just saying, oh, there’s a thyroid nodule, but looking at the ultrasound and gaging, how bad does this thyroid nodule look under ultrasound now that they’re so good. You can look at the borders. You can look at calcifications, these little factors that kind of go into even should I biopsy it.

Dr. Z: I see.

Dr. Ha: So before thyroid nodule biopsy it.

Dr. Z: Right.

Dr. Ha: And then some percentage of those are be cancerous and they’re like eight millimeters and you think, okay, that means total thyroidectomy that’s what the guidelines say. So that’s where things have changed probably, within the 2000s where we’ve become more conservative.

Dr. Z: That recently.

Dr. Z:  Yeah.

Dr. Ha: Yeah. So the most recent guidelines on 2015 and radical change. Yeah, so even like under a centimeter don’t even biopsy it even if you think it might be cancerous.

Dr. Z:  Interesting. Just one.

Dr. Ha: Which is tough.

Dr. Z: So what would you follow up?

Dr. Ha: Yeah, so these aren’t active surveillance basically. So to kind of keep an eye on that.

Dr. Z: The early ultrasound, six months.

Dr. Ha: If it starts to grow. Yeah, That’s right. And then you might biopsy it if it starts to progress.

Dr. Z: I see.

Dr. Ha: But it’s tough. It’s tough to tell a patient that. Like nine millimeters, it looks worrisome, we’re gonna follow it, could be cancer. and then they’re like, what!

Dr. Z: But see this is where this’ll separate the really good docs from the ones that are knee jerk that are actually acting emotionally themselves because I think we get paid to take those things out, right. And we’ve been conditioned that you do stuff to stop cancer. So the watchful waiting, even though the data that you cite says, not sure we’ve improved things by taking out your whole thyroid for an eight millimeter cancer.

Dr. Ha: Right.

Dr. Ha: Yeah. So, but it’s, it’s tough because the C word comes up and.

Dr. Z: Oh yeah.

Dr. Ha: It seems that you should be doing more than that.

Dr. Z:  Oh yeah. And patients have expectations.

Dr. Ha: Yeah.

Dr. Z:  Right. And they’re appropriate. It’s like, Oh my God cancer, are you kidding me? And so this is why this conversation is important because people don’t understand this. That sometimes doing less and watching, so you’re not doing nothing, that’s a key thing, you’re watching carefully. So my mother went through this in her 70s, diagnosed with incidental nodule. She had estrogen receptor positive breast cancer, had that treated, no problems there, radiation, lumpectomy. But then I just realized I’m violating my mom’s HIPAA, but I don’t think she, she watches the show. She’s watching this right now. I’m gonnao get a yelling at, but.

Dr. Ha: You’ll have to sign a waiver.

Dr. Z:  Exactly. Somehow I’ll blame you . But had a nodule too and it was, I think just shy of a millimeter or something like that and, biopsied and benign and watchful waiting, but a lot of stress.

Dr. Ha: Yeah.

Dr. Z:  Yeah.

Dr. Ha: No, it definitely is. And so, as an active 40 year old, if someone said, hey, there’s a nodule we’re watching, and I go, what, I gotta come back every year and get this biopsied or whatever, or followed, you might say, could you just take it out?

Dr. Z: Right.

Dr. Ha: I don’t want to deal with it and I don’t have to.

Dr. Z:  How do you, how do you respond to that?

Dr. Ha: Well, so actually the guidelines are pretty good about this is that basically they sort of given out for patient preference. So there’s a few different categories. So one is, there’s the eight millimeter person who, you say, look, we just really shouldn’t biopsy it. It’s too small. We probably aren’t gonna recommend doing anything about it, even if we knew, but if they’re really pushing said, okay fine, we’ll biopsy it. Then it becomes that cancer then you’re like, okay, so how far do you want this to go? So, and you talk about it with them and talk about the surgical risks and things like that. But there is a patient preference, kind of aspect to it, similar to other lumps and bumps, like a lipoma. Like a benign fatty tumor that sits under the skin. It’s not gonna grow, it’s not going to shorten their life, but if it bothers someone, then they’re like, well, we can take it out.

Dr. Z: Sure, sure, sure.

Dr. Ha: So I feel like there’s a little bit of that as well that, and this is even more serious than a lipoma.

Dr. Z: Right, right.

Dr. Ha: I think there is some judgment and some relationship that has to go into the factor.

Dr. Z: And do you do a full thyroidectomy for that or do you do partial?

Dr. Ha: We take out partial.

Dr. Z: Partial thyroidectomy.

Dr. Ha: We take about half.

Dr. Z: Right. And are they typically on replacement hormone after that?

Dr. Ha: 50% of the time.

Dr. Z:  I see, okay. So there’s a benefit to taking out less than the whole thing.

Dr. Ha: Yes, and so that guideline’s also changed for that. So, for these smaller nodules that seem independent, no lymph nodes around, then we can take out just half comfortably. Knowing that, we could always go back and take out the other half if we get the pathology somehow looks more concerning or something should grow there. So there’s a lot of factors that go into that decision. But yeah, it definitely reduces surgical risks and it makes it easier for the patient.

Dr. Z:  So what are the surgical risks of something like a thyroidectomy?

Dr. Ha: Yeah, so the biggest one I’d say that affects people is their voice. So there’s a nerve that controls the movement of the vocal chords, essentially like a V kind of swiveling back and forth.

Dr. Z:  Is it the recurrent laryngeal?

Dr. Ha: You’ve got it.

Dr. Z: Oh man, I got my medical school training at UCSF man and some of it stuck.

Dr. Ha: So yeah, so that, that helps the vocal chords move side to side. And so if one of those is weak, then your voice will be hoarse and potentially permanently so sometimes just operating on the nerve it goes weak, but then, it recovers. So the chance of it being really to the point where it doesn’t recover is less than 1%. So it’s not high, but obviously it’s something that can stay with you for the rest of your life. There’s another nerve that you probably don’t remember called the superior laryngeal nerve.

Dr. Z: No, never.

Dr. Ha: What that does is actually it’s kind of near where the thyroid sits as well but that actually helps tense the vocal chords. So you couldn’t do your music videos if that nerve were cut, but the recurrent was fine.

Dr. Z:  I’d rather die of thyroid cancer.

Dr. Ha: Yeah, you know what I mean so. So it does have a lot to do with like people who are professional voice users, whatever that means, right, if you’re teacher or singer or whatever it might be, but there are actually two nerves that you have to worry about, not just the movement, but it’s the pitch change, being able to tense and loosen the vocal chords to have intonation, so, those are at risk. And so for some people, again, everyone’s an individual, they go, I don’t talk much, just take it out, I don’t care. And the risk is low, but it’s not zero. So, it’s something you have to think about.

Dr. Z: See that, and again, this is having the conversation with the patient, doing what this, what’s the term, where it’s shared decision making, right?

Dr. Ha: Yeah.

Dr. Z:  I think that’s a term.

Dr. Ha: Yeah.

Dr. Z: And when we were running our clinic in Las Vegas, it was a lot of that. It was sitting down with a health coach, a doctor and going, okay, so the specialist said this, now let’s figure out what are your values? What do you care about?

Dr. Ha: Yeah and I think for this, it’s almost more complicated than if we have someone with a tongue cancer or a tonsil cancer where it’s like, okay, we gotta treat it, this is what we gotta do.

Dr. Z: Cause that’ll kill you.

Dr. Ha: Right.

Dr. Z:  Yeah.

Dr. Ha: And so the end result of you do nothing is not good. I hear you’re almost saying, let’s do nothing.

Dr. Z: Yeah.

Dr. Ha: So it’s kind of a reversal of what we kind of normally do.

Dr. Z:  How would you, so would you make a parallel to prostate cancer screening say where you get an elevated PSA because you’re testing and then it’s like, well, what do we do? Do we do a biopsy if we find most more people die with prostate cancer than of prostate cancer?

Dr. Ha: Yeah, so actually, if you look at the NCI, National Cancer Institute, they do publish guidelines for screening and that’s where all these PSA mammography and, various things. NAMA’s another one, yeah. So they review these and look at the data with a panel of experts and then decide, okay, should we offer screening? And how should we, or just the high risk, they kind of parse that out. In thyroid, it comes up from time to time, they kind of recycle it and look at new data. It’s never reached the point of a screening. So basically you could cause it, we pretty noninvasive just do an ultrasound and just kind of lined people up and here’s what the early ultrasound, but they realize that we’re gonna catch too many things and we’re gonna have to do things and the cost would be tremendous and people will worry about it, and we’re not gonna be saving lives.

Dr. Z: Right.

Dr. Ha: So it’s kind of interesting in that sense.

Dr. Z: And let’s contrast that to something like the Japanese do using upper endoscopy to screen for gastric cancer. So this is an interesting counterexample of where something that. So what this means is for people who don’t understand this idea, putting a scope down the throat into the stomach to look for early signs of gastric cancer. Now gastric cancer in the U S is relatively rare in Japan. There’s a much higher prevalence of it because of maybe diet genetics mix of things like that. And they found that it’s actually effective to do that screening cause they’ll save lives at a cost that’s manageable.

Dr. Ha: Yeah. So that’s actually an interesting parallel to that is for thyroid actually. So one of the risk factors is radiation exposure. So if, for example, at Chernobyl or Therma Island or someone who’s been exposed to radiation or group of people, they actually do get screened.

Dr. Z: Make sense.

Dr. Ha: Yeah, because they’re at higher risk for developing thyroid cancer so, that’s actually a good use of screening, but again, it’s not widespread screening.

Dr. Z: And this idea of again, screening the appropriate population is important. So if we’re talking about, let’s make a parallel to COVID. We have limited testing resources for some reason which we’ve talked about multiple times on the show, even had the Chief Medical Officer of Cepheid on here, who makes the test, and the idea that, okay, we don’t have all this ability to do it. So who are we going to screen? Well, how about healthcare populations, nursing homes, people at our highest risk, you wanna go where the prevalence is high, so that there’s less likelihood that you’re gonna have a false positive in a low prevalence population. You’re not wasting money and resources and you’re not finding false positives that then you have to follow up and cause harm to.

Dr. Ha: Right.

Dr. Z: Yeah.

Dr. Ha: Yeah so I think that’s, in this scenario the screening, it’s not screening, but let’s say the fact that they’re in your office for this thyroid nodule has happened. So it’s been identified. So then the question is then what do you do about it? Right, and where do you go from there? And that’s where, I think because of this, it’s happening more often, the cytologists the people who do the needle biopsies, they stick a tiny little needle, numb it up and just suck out some of the cells out of the nodule, they’ve gotten really good at determining what this could be, but there’s still sort of this black box of an area where they can’t quite tell and no more additional needle biopsies are gonna be able to determine this ’cause they need to look at the way the cells are arranged let’s say.

Dr. Z:  You have to pull out a chunk.

Dr. Ha: Correct.

Dr. Z: Yeah.

Dr. Ha: And that’s just not that feasible in a thyroid. So then they develop another layer of molecular tests. So where you can look at the proteins of the RNA and the DNA and trying to get a score and say, okay, how worried are we about this or how comfortable are we.

Dr. Z:  And it’s a probabilistic thing? It’s not a black or white answer.

Dr. Ha: Right, although it’s pretty good for saying it’s not cancer.

Dr. Z: Okay.

Dr. Ha: So the test will say, okay, there’s a 98, 99% chance that it’s not cancer and that is really the most important thing actually.

Dr. Z:  Yeah.

Dr. Ha: But it doesn’t, the flip side, it doesn’t guarantee that you have cancer. So we’ve done many of these where they said, look, we can’t say that it’s not, but, so it puts it about a 40% chance that it could be cancer.

Dr. Z: I see. That’s a real gray area.

Dr. Ha: Yeah so we’ll go after those, take them out.

Dr. Z: I see.

Dr. Ha: But we’ve seen just as many of those turn up negative ultimately so, but it is good, I think that’s helpful for trying to determine, okay, we’ve got this nodule, doesn’t look that bad in ultrasound, but it’s kind of big, it’s grown a little bit. The needle biopsy was indeterminant. So then let’s get this blockage test. So more and more insurances are now covering that and that seems to be a good way to try to get people into that active surveillance mode and comfortable with their diagnosis.

Dr. Z:  That’s good. So that’s another tool in our armamentarium that doesn’t just lead you right away to cut open.

Dr. Ha: Yeah, that’s right. So it means that the thyroid surgeons are getting less busy.

Dr. Z: Right.

Dr. Ha: But we don’t mind. We wanna do the right thing for the right patient.

Dr. Z:  And yet you all just had something similar happened with prostate and that it’s advancement you want that? Yeah. So relating to that then, so let’s say you do get a cancer diagnosis. There are different types of thyroid cancer.

Dr. Ha: That’s right.

Dr. Z: So how would you think about them in terms of what you do and how the treatment is and what the outcomes are?

Dr. Ha: Yeah, absolutely. So the most common is something called papillary thyroid carcinoma or BTC, and of the cancer group that’s about probably 80% of them. So most common, it’s also the one that behaves kind of the most favorably in many ways. It was again, interesting biology is that it can spread to lymph nodes and

Dr. Z: Capillary, yeah.

Dr. Ha: Yeah. And so even though it does that, it doesn’t necessarily always change your prognosis. So it may change the fact that there’s more that we have to do, more surgery giving radiation and things like that, but the actual survival remains pretty close to the same.

Dr. Z: Oh.

Dr. Ha: Okay, so and then there’s follicular, which is about 10 to 15% of cancers. And so paplin follicular the large majority of thyroid cancers and we call those together the well differentiated group. All that means is that they kind of behave and retain a lot of the characteristics of normal thyroid cells. So they’re generally more favorable. They’re easier to treat, and patients do well with them. Then you start going to another groups of medullary thyroid cancer. So just it develops from a different cell type within the thyroid, and that’s about 5% of them. And these it’s an unusual group of tumors, but they actually can be familial. So the’re certain syndromes.

Dr. Z: Like “Boys 2 MEN”?

Dr. Ha: Yes MEN2.

Dr. Z: And MEN2.

Dr. Ha: Yeah, and so it can be linked with that and so if you see a strong family history of thyroid cancer, like just over and over again, ’cause the penetrance, meaning the fact that they actually get thyroid cancer, even if they have this gene is very high. So you’ll see that really tracking families. Papillary and follicular, they actually don’t so much. And so, a lot times people think, oh my dad had cancer, my mom had this or a thyroid goiter or a nodule, that may just be chance.

Dr. Z: Yeah yeah yeah yeah.

Dr. Ha: It’s not so say as heritable, whereas medullary you really have to look for that and go, oh, this is heritable.

Dr. Z: So quick question, not to derail you but so if the penetrance of that gene, in other words, you’ve got the gene, the chances of you getting thyroid cancer are quite high medullary thyroid cancer. Have you seen a lot of people coming to you with like 23 and me results saying, hey, I have this gene, like?

Dr. Ha: Not usually. I’d say that most of the times they’re aware of it, I think. A, it’s pretty rare.

Dr. Z: Yeah.

Dr. Ha: And then B is that they know it. And there are certain forms of MEN where like in pediatrics, you’re doing the thyroidectomy. I don’t start doing them, but they’re coming through, they’re taking out the thyroid prophylactically.

Dr. Z:  That’s what I mean.

Dr. Ha: Yes, yeah.

Dr. Z: So you’re getting people saying, hey, can you take this thing out? Like an Angelina Jolie’s. Scenario.

Dr. Ha: So, basically if you identify this, you need to check. I’m having a

Dr. Z:  There’s a bug yeah.

Dr. Ha: Pence situation.

Dr. Z:  Yeah Pence situation, yeah exactly. Jeff Goldblum on your head. Sorry with the windows open, ’cause we keep the ventilation going now we get bugs.

Dr. Ha: No worries. So yeah. So basically, if you identify some with medullary cancer, you need to do the genetic testing, and then if they have, and you realize that it’s not the sporadic type that just comes up randomly, but it’s familial, then you need to have their family tested, kind of go through all

Dr. Z: Do the whole thing, yeah. So tell me about medullary and the outcome’s worse.

Dr. Ha: Worse, if it’s caught early, it’s not too bad, but yeah, as it starts to spread to lymph nodes and things like that, then it is definitely far worse than papillary and follicular, which are very good, like really high on the bar. Medullary is somewhere in between. Then there’s poorly differentiated or anaplastic cancer. And that’s kind of the worst where I actually think it’s one of the fastest growing tumors that we ever encounter and perhaps in other parts of the body as well, but it can be rapidly progressive, and oftentimes if it’s not a situation where you took out the thyroid thinking it was papillary and they see anaplastic, then actually there’s a chance that that patient might do okay. Patient comes in with anaplastic, ’cause it’s, they have a huge thyroid mass they’re generally not gonna do so well. And so it’s often unresectable by the time they see you and then you worry about their airway is a big thing. So, it’ll compress the trachea, compress the wind pipe.

Dr. Z:  ‘Cause it grows so fast, yeah.

Dr. Ha: Yes it to grows so quickly and we don’t have great treatments for it.

Dr. Z:  Sounds like that’s a nasty, poorly differentiated, really genetically disrupted tumor.

Dr. Ha: Yeah. And so that is, and told you that about the incidents of people passing away from thyroid cancer, hasn’t really changed much that.

Dr. Z:  Right.

Dr. Ha: The number, I guess. That group sort of resides within there, right. So the anaplastic thyroid cancers almost universally do poorly. They don’t usually last more than a year or two. And then that comprises that group most likely.

Dr. Z: I see.

Dr. Ha: And then there’s a layer on a little bit of the other groups kinda sprinkle in there who don’t do so well from their disease, but largely it’s anaplastic patients who don’t do.

Dr. Z:  Anaplastic. So, and again, I hate keeping parallels to COVID because people need to understand how we process numbers and statistics and stuff. It’s, it’s a similar idea. It’s this kind of parado distribution that like 1% of the tumors, cause 90% of the fatalities.

Dr. Ha: Yeah.

Dr. Z:  And in COVID, a very small part of the population causes the vast majority of deaths and that’s people over 65 people with two chronic diseases doesn’t mean it can’t hurt other people.

Dr. Ha: Right.

Dr. Z: But that that’s something to understand in our mind and it’s the same with thyroid cancer. So a related question to this and feel free to school me if it’s even a dumb question. So people with like Hashimoto’s with Graves’ with these other endocrine thyroid disorders where there’s a miss jiggering of a production of hormone or autoimmune stuff going on, are they at higher risk for thyroid cancer?

Dr. Ha: They can be, they can be. And so again, some of it’s a little bit hard for me to know, because they’re typically under the care of an endocrinologist.

Dr. Z: Right.

Dr. Ha: And having these checked out, so it may be that there’s just a bit of

Dr. Z: Vigilance.

Dr. Ha: Yeah. That they’re being looked at. So maybe those numbers a little higher, but there is probably a slight increase, of thyroid nodule to thyroid cancers.

Dr. Z:  In either of those cases, they say Hashimoto Graves’. Okay, got it, yeah. ‘Cause Hashimoto’s is an under production because of autoimmune and Graves’ is overproduction.

Dr. Ha: Well, so Hashimoto’s is sort of like a, it’s just like an inflammatory condition. Graves’ is truly an autoimmune.

Dr. Z:  Antibodies.

Dr. Ha: Yes, correct.

Dr. Z:  Right. It’s anti thyroglobulin.

Dr. Ha: Yeah, so and thyropreoxidase.

Dr. Z: That’s where TPO, Yeah, yeah.

Dr. Ha: So they can have like the bulging eyes and all these sorts of things. So they can be, sometimes we have to manage them surgically because they can’t tolerate the medicines to keep the thyroid at say. So we will sometimes have to operate on them, but it’s not usually for a cancer related.

Dr. Z: I see, I see. By the way the bulging eyes, that’s a cross antibody to optic something or the right.

Dr. Ha: Yeah, that’s right. Yeah, so it’s not that the thyroid is somehow in the eye or anything like that.

Dr. Z: That’s right.

Dr. Ha: It’s just a weird.

Dr. Z:  It’s an immune crossDr. Ha: reactivity, right. Interesting, the body is an amazing thing.

Dr. Ha: Crazy, isn’t it?

Dr. Z:  It does some crazy complex things and then we come along with our infinite hubris, we understand it, not yet, yeah, not yet.

Dr. Ha: It’s not that easy.

Dr. Z:  Yeah.

Dr. Ha: Another thing we should talk about is the concept of a goiter.

Dr. Z: Yeah, tell me about that.

Dr. Ha: Yeah, just because.

Dr. Z:  I pronounce it goiter by the way.

Dr. Ha: I spell it RDr. Ha: E. So yeah, it’s, a goiter just means like an enlarged thyroid and so I think sometimes people cross or conflate the idea of a cancer and a goiter. So basically the thyroid can sometimes enlarge for, again, we don’t know why it just happens and basically you get multiple nodules and the thyroid can become very large, to the point where it can restrict swallowing or breathing and things like that, or just visibly, it just looks funny so people are tired of it.

Dr. Z: And that can be a benign process.

Dr. Ha: Most of the times it is actually.

Dr. Z: Yeah, yeah, yeah.

Dr. Ha: In areas where there’s no iodine, if you’re iodine deficient, then that’s sort of where it first was discovered that, hey, if you don’t have enough iodine, the thyroid basically it just enlarging, I think it’s so hungry to try to function, but that’s why we have iodized salt.

Dr. Ha: Right. So, basically there’s a little bit of iodine thrown into things and so that with the course of a regular diet, you won’t become iodine deficient at least in the Westernized or, non third world country. But then despite that there’s other goiters that can happen that just for whatever reason the thyroid takes off. And so those we actually will need to operate on oftentimes just because it’s too big or it’s causing compressive symptoms. There’s a fun sign called Pemberton sign where if you raise your arms over your head, it pulls the thyroid up and becomes, like hard to breathe. You feel like more pressure.

Dr. Z:  Oh, interesting. Pemberton sign.

Dr. Ha: Yeah, you can go look it up.

Dr. Z: I would have called it the Beavis and Butthead Cornholio sign. Cause if you’re like, I am Cornholio, I need TP for my bunghole.

Dr. Ha: Then you can’t breathe.

Dr. Z: You can’t breathe, right, yeah.

Dr. Ha: So yeah.

Dr. Z: Shut up Beavis.

Dr. Ha: I think a lot of your viewers are not gonna get that reference.

Dr. Z: Yeah, yeah, yeah, well, you’d be surprised.

Dr. Ha: It’s starting to get dated.

Dr. Z:  It is, so am I though.

Dr. Z: Yeah.

Dr. Ha: Yeah. Aren’t we all.

Dr. Z: Yeah.

Dr. Ha: So yeah. So anyway, so we, we do a fair amount of, surgeries for enlarged thyroids and universally or, not universally, but by enlarged, those are nonDr. Ha: cancer related or sometimes you find an incidental, small cancer but you’re doing it for a different reason.

Dr. Z: ‘Cause almost like a breast reduction surgery, except breasts are not pathologic, right.

Dr. Ha: I have to process out for a little bit.

Dr. Z:  See I make very strange analogies that make no sense even to me. So this idea then that this is talking about like multinodular goiter. So how do you think about that in terms of cancer risk? Because this comes up a lot.

Dr. Ha: Yeah, so, basically you can’t biopsy every nodule, ’cause sometimes there’s maybe 30 of them. So, it’s still worth doing an ultrasound to look around, to see if there’s anything that catches your eye or somehow meets criteria for biopsy, but it just seems that most of the times where there’s multiple nodules, it tends to be benign. And then your decision for surgery is not so much because of cancer, it’s are you having symptoms? Is it growing over time? So you might follow them with ultrasounds, just look at the size of it and that to sort of predict, okay, you’re 40, it grew a centimeter over the past year what’s gonna happen by the time you’re 50?

Dr. Ha: Right.

Dr. Z:  It’s gonna be too big, so let’s do it now.

Dr. Z:  You’re going to be all Pembertoned out.

Dr. Ha: Yeah.

Dr. Z: Yeah.

Dr. Ha: You don’t want that to happen.

Dr. Z: Can’t reach for the

Dr. Ha: The light bulb.

Dr. Z: The light bulb.

Dr. Ha: Right.

Dr. Z:  So relating to that. So those kinds of surgeries are those total thyroidectomies or are they partial thyroidectomies?

Dr. Ha: It depends. It depends on if it’s affecting both. It’s weird. Sometimes both sides are very big. Sometimes there’s one side that’s huge the other side is normal. So it kind of depends on what your goals of the surgery are.

Dr. Z: And are those surgeries higher risk for complications with nerve damage then say a cancer surgery?

Dr. Ha: Good question. Yeah, they are.

Dr. Z: They are.

Dr. Ha: Slightly. So, it’s a little bit harder to see things the bigger it gets and it’s a tight space. We also tend to make smaller incisions ’cause we don’t want it to be as visible.

Dr. Z: Right.

Dr. Ha: And so we’re, we’re working in a narrow field basically. So yeah. So if it, the bigger it gets, it’s not necessarily linear, but there comes a point where like, oh, this is now gonna be a little bit hard.

Dr. Z: Are robotics a thing in thyroid surgery.

Dr. Ha: It depends. I think there’s been a lot of evolution and I guess maybe ’cause I’m older, but a lot of it is, it’s necessarily that much of an advantage to it in the sense that, it’s true that you do get some visualization advantage, but to get there and deploy it, you’re going through a lot more to get the instruments in there. It’s not as natural as just making a small incision right over where the part is that you’re working.

Dr. Z: Right.

Dr. Ha: So you tend to make distant incisions. So for a while, there’s a transaxillary to make a cut through the armpit tunnel over to get to the thyroid. They’re now doing trans oral, where they go through the lip actually, like in the gutter of your lip and your teeth and then tunnel down and get here. So, some of these approaches are better for certain areas, like you can see better, but most of them are actually designed to move the incision.

Dr. Z: I see.

Dr. Ha: Right, you’re moving out of here to somewhere that’s hidden.

Dr. Z:  Is that that’s purely an aesthetic decision or?

Dr. Ha: Really yeah at this point.

Dr. Z: Yeah, yeah, yeah. So say you’re a model or something.

Dr. Ha: Right.

Dr. Z: It matters.

Dr. Ha: If it means a lot then it can be done.

Dr. Z: I mean, again, our patients value different things.

Dr. Ha: Yeah, and we like technology. We like to see what we can do

Dr. Z: But she is a double edged sword.

Dr. Ha: It can be, that’s right. So, I think you just have to think about it judiciously and I think for the right patient it might be the right thing.

Dr. Z: Right.

Dr. Ha: But I also think, and we didn’t talk about this as much, but like the volume of surgeries that you do probably matters.

Dr. Z: Yeah.

Dr. Ha: And so, for this particular, for thyroidectomy in general, it’s a good thing to have done, having a regular part of your practice as opposed to doing one or two a year, because then that routine, it gets harder to manage. Likewise, I think with robotic or distant access surgery where you’re doing either endoscopic or some other approach, it’s better to do many of them that way, as opposed to as 1% of what I do and I do 99 regularly. You do need to create a situation where, okay, I’m doing 30, 40, 50 a year, so that you feel that it’s not new every time you do it.

Dr. Z: Yeah, I feel like that talking to a lot of surgeons and also kind of people who manage surgeons, it look from a quality standpoint.

Dr. Ha: Yeah.

Dr. Z:  Volume matters so much. Like you said, I mean, because it just becomes there’s a, you can describe it better than me, with the muscle memory and a general aptitude that requires high volume.

Dr. Ha: Yeah, no, for sure. And I think, these are small structures they’re really delicate. And then theoretically, we’re actually doing fewer, right, because we’re, we’re watching more, we’re biopsying less and so there’s still quite a number of thyroidectomies being done, but it is starting to dwindle a bit.

Dr. Z: So a center for excellence or a surgeon that’s just does a ton of them is important. There are fewer of those, which means you’ll have to travel potentially.

Dr. Ha: Potentially, yeah, but I think it’s probably worth at least talking with them and understanding kind of what the differences would be.

Dr. Z:  How would you tell people if they have a thyroid nodule and they’re looking for a surgeon or somebody that they, how would they look for a good surgeon.

Dr. Ha: So a lot of it has to do with referral patterns.

Dr. Z: Right.

Dr. Ha: And so, endocrinologists or primary care physicians are often the ones seeing these people first. They’re not automatically seeing a surgeon or a specialist, right off the bat. So those are good resources, right. So the endocrinologists, and often they follow up with endocrinologist or primary care physicians when they’re managing their thyroid hormone and they all come back talking like this, then you go, ah, they really don’t know what they’re doing. So there’s those things that they can do to figure out like who are the best surgeons and who seem reliable. And you know.

Dr. Z:  It does sound like again you’ve got to put some weight on those primary care physician quarterbacks to generate those good guy networks of people they trust and that means that we ought to resource those guys appropriately, which means transform medicine a little bit from you specialists running everything to maybe all of us together running everything.

Dr. Ha: Well, no, and I think that, and we talked about before, but I think, access is a big issue. So, we’ve done everything we can to make it easy. And then a lot of it is relationship building so that, if we do get a referral from someone that we don’t know, we give him a call and say, hey, let’s talk about this case and let’s talk with the patient, what are the plans? And that goes a long way in developing that and then it just becomes easier the next time.

Dr. Z:  See that’s huge. And again, it generates a collegiality to that we’ve been missing a little bit since we’ve, so many entities now send referrals is an epic staff message or a button that says consult ENT or head and neck oncology.

Dr. Ha: Yeah, I mean, it is more efficient, but you’re right. That there can be nuances that are missed. And it’s like, hey, this patient is pretty challenging or whatever.

Dr. Z:  How many times has that happened? I mean, every time if I just actually do a face to face. As a hospitalist, if I go talk to the ER doc face to face, I find nuance or the nurse even better, ’cause then you go, oh, that’s what’s going on with the family dynamic or that’s what the patient wasn’t telling us.

Dr. Ha: Yeah, and you can’t chart that, right, they’re subtle things that you kind of pick up. And that’s also why, for example, when we run our team, we have our team, tumor boards every week with the radiologist, with the pathologist, even though they’ve written a report, we review it.

Dr. Z: Yeah.

Dr. Ha: And then the verbal things they tell us like, oh, actually. And it goes back and forth, ’cause we might say, oh, I’m actually worried about that part. And they go, oh, I didn’t know that, let’s look at that. And then, so, there’s an interplay that can happen that sort of is deeper than just a written report.

Dr. Z:  You know what it is, new trainees don’t understand this. They miss this idea, that actual discourse and going and seeing the scan with the radiologist and going through it actually makes a difference. They expect, it’s just gonna show up as a report and that, okay, well, that’s what it says so that’s the truth. It’s like, no, that’s not how medicine works.

Dr. Ha: Yeah, I mean, I think it’s obviously you have, again, you have to trust the radiologist.

Dr. Z: Right.

Dr. Ha: And there’s often a team that you might know a couple of them, but not all of them and so, you just see, you look at the name on the report.

Dr. Z: Yeah, and then you go, okay, this is good.

Dr. Ha: Yeah, or how do I call them, or, you know?

Dr. Z: Right.

Dr. Ha: But, but I think at least for my cancer standpoint, that’s where we have little margin for error.

Dr. Z: Yeah.

Dr. Ha: Right, we don’t, we can’t be wrong.

Dr. Z:  Right.

Dr. Ha: And then we wanna go into the surgery and the treatment plan whatever it is feeling like, okay, I am armed. I have everything kind of teed up and to the best that I can, then I can put forward the plan.

Dr. Z: How has it been during COVID with teaching house staff and access and those kinds of things at UCSF with you?

Dr. Ha: Yeah, actually with house staff a little change. We did a little twist during the deep part of COVID where things are a little more uncertain where we cohorted. So basically we just separated teams and stuff on the cancer team there’s two teams. From surgeons to reconstruction, to residents, and and fellows so that we never really crossed paths. So we actually took shifts almost like you were Monday, Tuesday, Wednesday, you were Thursday, Friday, Saturday, and then we kind of flip flopped so that if one team did fall sick, that there was a backup team that it wasn’t like the whole team had to go out.

Dr. Z: Got it.

Dr. Ha: The good thing is, is that honestly, nobody got sick, nobody got symptomatic, no one had to take days off, even for quarantining.

Dr. Z: And you guys are high risk in the sense that you’re in people’s faces.

Dr. Ha: Yeah, so there was a lot of uncertainty about that too, in the sense that that is where Corona lives. It’s right in the nose and in the mouth and the mucus membranes and so, I think we have to just give props to the community that has been doing a great job of masking and trying to stay socially distanced and so the incidence is low. So what it meant is that the incidence in the hospital is low.

Dr. Z: Yeah.

Dr. Ha: So it’s societal.

Dr. Z:  Yeah.

Dr. Ha: So I think we.

Dr. Z: This is San Francisco we’re talking about.

Dr. Ha: That’s right, yeah.

Dr. Z: They’ve been really good about it, yeah.

Dr. Ha: So I think we got a little luck from that. A lot of my colleagues from across the country just, they had to shut down. They couldn’t even do these surgeries anymore because there was no space.

Dr. Z: Wow.

Dr. Ha: And then there’s some groups that were very afraid to examine people or put a scope down someone’s nose and things like that. And so I think in that sense, they would try to get around it, like look at scans and do things a little bit less invasively. But yeah, well we, we sort of carried on and I think the trainees appreciated that.

Dr. Z: What’s your PPE situation. How do you go into these rooms?

Dr. Ha: Yeah, it depends. It’s complicated.

Dr. Z: ‘Cause there’s an aerosolizing procedure.

Dr. Ha: That’s right. And so even the definition of an aerosol

Dr. Z: Right.

Dr. Ha: I think is challenging. If someone sneezes.

Dr. Z: That’s aerosolized .

Dr. Ha: To me it is

Dr. Z: And droplets.

Dr. Ha: But to other people they say, oh, that’s just droplets.

Dr. Z: Right.

Dr. Ha: And so, I think that definition is a little bit challenging and so some of it is just individual in the sense that, we have guidelines UCSF is pretty good about, and the guidelines it’s, it’s often not a must, or should it’s consider or it depends, right so.

Dr. Z: Yeah.

Dr. Ha: So now that PPE is not so much an issue in terms of the scarcity of at least where we are, I think that if people wanna wear an N95 and a face shield, just look in the mouth, I think that’s fine.

Dr. Z: Yeah.

Dr. Ha: The guidelines would say that you don’t need to do that. On the other hand, if we scope someone like put a tube down their nose to look down there or camera down their nose to look at things then we have to put on an N95 and a face shield.

Dr. Z: Got it.

Dr. Ha: And if someone has a tracheotomy or a laryngectomy and we’re gonna have to instrument that, then likewise, we would protect ourselves.

Dr. Z: And at UCSF right now is everyone surgical face masks 24/7 when you’re in the hospital or.

Dr. Ha: Goggles, yeah. Some sort of eye protection, I guess as a

Dr. Z:  Eye protection too, yeah.

Dr. Ha: Whether that’s face shield, goggles, various.

Dr. Z:  So you go into the lounge and you’re hanging out with people, you’re still goggling up.

Dr. Ha: I don’t go to the lounge. Yeah, I mean we go in, we do our work

Dr. Z:  And you can you get out.

Dr. Z:  Yeah.

Dr. Ha: Yeah, exactly.

Dr. Ha: But yeah, it’s tough because it’s hard, especially if your colleagues are there and you wanna chat or you wanna drink a cup of coffee, then everything starts to, you can’t basically, you have to change what you do. But I think our team has been pretty good about maintaining social distance. On these teaching conferences, we all just split up, we don’t congregate to, look all at the same screen, we don’t have to do that.

Dr. Z: Right.

Dr. Ha: You can just pull out your laptop, your phone and take it remotely in the waiting room or something like that in a chair.

Dr. Z:  And your nosocomial outcomes have been great. I mean, health care workers have not gotten very sick.

Dr. Ha: Yeah, again, we’ve been very lucky. But certainly on our team, nobody’s gotten sick. Now that a resonance and so, knock on wood, we’ve been fortunate.

Dr. Z: It’s great. So it just shows it can be done, yeah.

Dr. Ha: Yeah, and I think it is a culture shift, but I think the way I explained to one of my patients was that it’s not so much me that I live in fear of myself getting sick.

Dr. Z: Yeah.

Dr. Ha: It’s more so than I think I have responsibility to everyone around me. And then the thing is that even just an exposure means we have to quarantine.

Dr. Z: Yeah.

Dr. Ha: Which means then we’re out for two weeks and we can’t do our jobs and then all those patients that we have lined up, we have to figure out how are they gonna manage? So there’s this trickle down effect and so, I think that if you yourself feel like, okay, I think this is a little risk and whatever, but it’s more so that, that exposure risk, meaning that you then have to come out the pool essentially, ’cause you don’t wanna spread it to other people that’s burden I think.

Dr. Z: Big hit. I’ve noticed that with a lot of doctors actually like yourself, they are very cautious in public everywhere, very cautious, like beyond the risk to themselves. Because again, they may be low risk and it’s for that reason, it’s exactly for that reason. Whereas I get up in people’s faces, just rip my mask off. I mean, my mask is placebo. It’s just, it’s a Victoria secret.

Dr. Ha: Like a mesh

Dr. Z: Raw mash, right, yeah, and I’m just breathing through it because I just waned to be edgy. But no, no, no, I’m kidding. I always wear a mask in public and I think it’s a minimal ask for me. Now there are people whose moral matrix says, that’s an infringement on my rights and so on. And I look, I understand that the thing is, we’re trying to get through this with again, it’s what you value. Do you value care versus harm? The idea that you might hurt other people or yourself, or do you value Liberty versus oppression or do you value, and this country has got a diversity of values so, it’s a strength and a weakness.

Dr. Ha: Yeah, I totally agree. I think that it’s a lot of individual opinions out there and it’s hard to have data, and sort of in many ways, people like to fall back on data. It’s like, well if it doesn’t prove it then why should I not do this?

Dr. Z:  Yeah, yeah.

Dr. Ha: But I think, the thing about a mask is that it’s not that hard.

Dr. Z: Yeah.

Dr. Ha: They’re easy to get. It doesn’t really change your behavior necessarily. So it seems like that’s a fairly simple intervention.

Dr. Z: Right, right.

Dr. Ha: And then obviously within the hospital, then we step it up.

Dr. Z:  Yeah, for sure. Yeah, yeah. Yeah, and so speaking of like virtual learning, ’cause you’ve brought that up, you’re doing a thing.

Dr. Ha: I sure am.

Dr. Z:  Yeah. Tell me about this thing.

Dr. Ha: Well, so every two years we run a course and it’s a CME course or, for physicians and allied health professionals.

Dr. Z:  So nurses, nurse practitioners, PAs everybody’s.

Dr. Ha: SLPs and the whole group.

Dr. Z:  SLPs too. Right, because you’re so tightly working with speech.

Dr. Ha: Yeah, so actually for this conference, it’s usually in person and so, we like to show off our Bay area and have a good time here but this year we obviously realized that that’s not feasible so we’re still running it. We’re doing it virtually.

Dr. Z:  Would you be like, okay, here’s where half of our state burned down. Here’s a smoke bank.

Dr. Ha: Yeah, there’s not a whole lot left.

Dr. Z:  Yeah.

Dr. Ha: But yeah. So it’s a two day course typically and the nice thing was is that because it’s virtual, we actually could expand our speaker list.

Dr. Z: Oh nine.

Dr. Ha: So normally we have three or four people from out of town and now we really increased that number. So thanks to all the people who agreed to do it. But then, so that’s running for the first two days and that’s covering basically head and neck surgeries. So all the things that we talked about and management of patients. And then the third day, it’s a separate course, but it’s actually run by our SLP team. So I’m participating in that as well. But it’s gonna be a days worth of talks about how to manage head and neck cancer patients and sort of the specialty specific areas of that.

Dr. Z: So for the speech language pathologist, so that’s huge, ’cause they’re a big group of our audience and they’re always asking like, can you do something for us? Can you.

Dr. Ha: Yeah.

Dr. Z:  So this is a great way to get them up to speed on that particular aspect of management.

Dr. Ha: Yeah and they can do both. I mean, and the other nice thing is that just because we know it’s inconvenient for a lot of people is that, for the registrant’s we’re actually giving them 30 days of you can just watch the lectures. And so if you were like, oh, I can’t make it Friday, but Saturday, Sunday sound great or.

Dr. Z: It’s accessible.

Dr. Ha: Then they can watch it again.

Dr. Z: That’s great.

Dr. Ha: Yeah.

Dr. Z: And people can use their CME budget to pay for this and that kind of thing.

Dr. Ha: Yeah.

Dr. Z: Yeah.

Dr. Ha: Yeah.

Dr. Z: And so what we’ll do is we’ll put a link up. What’s the conference called?

Dr. Ha: It’s complicated.

Dr. Z: Typical.

Dr. Ha: Yeah, so it’s better if we will post the link.

Dr. Z:  There we go. We’ll post the link and you guys can sign up and maybe you can put in whatever notes or comments that you learned about it from our show. That way Patrick will be impressed with our reach.

Dr. Ha: That would be great. Our marketing department would love that.

Dr. Z: That’s right. By the way, just full disclosure, Patrick’s not paying me anything. We’re not making a. This is purely, I think it’s a great thing that he’s doing and yeah.

Dr. Ha: Yeah, I think it’s great. And I actually, again, off-topic, but we were able to get one of our speakers from Africa actually gave an endowed lecture, this is separate. And through that connection or actually inviting the head and neck surgery group from Africa, sort of throughout the continent.

Dr. Z: That’s awesome.

Dr. Ha: To participate. So I think it’s just a way that, even though like, if this were just in, San Francisco, people couldn’t make it. But now we actually have the ability to reach out internationally even

Dr. Z: Yeah, yeah.

Dr. Ha: To have, invite people and to participate and to learn. So it’s actually, as much as, no one wants COVID to happen, no one wants social distancing, we’re trying to make the best of it.

Dr. Z: Can you speak for yourself? This has been the greatest thing that’s ever happened to me. I’m actually a, quite a misanthrope. Patrick’s like one of the like three people I hang out with ever, right, and otherwise I’m perfectly happy to have this kind of distance. But what’s interesting in Africa though, there’s, isn’t there, I forget now I’m trying to remember from medical school is Epstein Barr related or Naesa Frangela. What’s the deal in Africa that’s specific to their head and neck.

Dr. Ha: It’s hard to. I’d say that the biggest thing that we learned is the, just the lack of access.

Dr. Z:  Access again, yeah.

Dr. Ha: And so, it’s interesting, we were looking at numbers of, let’s say head and neck surgeons in all of Africa, there are 17.

Dr. Z: What!

Dr. Ha: And that’s 1.2 billion people.

Dr. Z: For a continent.

Dr. Ha: Yes.

Dr. Z:  1.2 Billion people, 17 head and neck surgeons. So you can see that’s a center for excellence.

Dr. Ha: All scattered without.

Dr. Z:  Scattered everywhere.

Dr. Ha: Yeah, and so, the statistics are just sobering. You think, well, how many does that mean for the Bay area? That would mean, not head and neck surgeons even, but 3.3 otolaryngologists.

Dr. Z: Wow.

Dr. Ha: So ENT surgeons three for this entire, several million

Dr. Z:  Population.

Dr. Ha: Population, right. And so I think that a lot of their issues are not so much just the different types of cancers where they can do, but it’s just a limitation of and just getting in to see the surgeon traveling, radiation and chemotherapy, right.

Dr. Z: Yeah.

Dr. Ha: So it’s just so many different issues.

Dr. Z:  It’s been merciful that they haven’t suffered as much fatality from COVID and it might be younger population.

Dr. Ha: Yup.

Dr. Z: Yeah, there’s a lot of theories why that is, but it’s interestingly something we can learn from in the West from Africa. But dude, Patrick, man, it’s always like, I’m so glad we’re practically neighbors now, right. Like we should do more of this and I think there’s other topics people are really interested in head and neck.

Dr. Ha: Yeah, I’d be happy to learn and to get feedback and see what we can talk about.

Dr. Z: Absolutely, we do it every time. This is our third show now and I always learn something and look as a hospitalist, like I’d be consulting you and just let you write your note. I don’t need to learn anything, Patrick’s got it covered, right. But now I’m like, well, this is really, ’cause again, this idea of virtual learning has now suddenly it’s taken this public sort of consciousness, but this is something that we’ve been kind of trying to do via the show for forever. And I think go to where people are, they’re on social media and maybe there’s one person out there who now is gonna reframe how they think about an incidental thyroid nodule that was discovered on them or their loved one or something and reapproach it, and even in how they find a doctor.

Dr. Ha: Yeah.

Dr. Z: Dude, it’s awesome to have you on the show, man. We’ll get you next time. Guys, if you appreciate the kind of stuff we do become a supporter, the show on Facebook, on YouTube, you can also just like do one time donations on PayPal and I’ll send you a little email. But really I want you to be a part of the tribe because we have this like closed discussion group where we talk hella smack dude. And it’s like, people who wanna be there so they don’t troll each other, they’re like really kind to each other. And check out the link that we’re gonna put to Patrick’s CME conference, because it’s gonna be dope if you’re into head and neck stuff or if you’re a speech and language pathologist, ’cause that would be the bomb. I love you guys, stay well, stay woke, and we out peace.