Surgeon Preference for Maximizing Medical Care Is Associated with Recommending More Extensive Surgery for Low-Risk Thyroid Cancer

Methods

A mixed-mode, cross-sectional survey was administered in September 2020 via mail and email to 222 thyroid surgeons identified in the Centers for Medicare & Medicaid Services Provider Utilization and Payment Physician and Other Practitioners dataset. Details about developing, piloting, and administering the 20-question survey were published previously. ⁸ Institutional Review Board approval was obtained.

Participants were asked their treatment recommendation for a healthy 45-year-old woman with a solitary 2.0-cm PTC. The case noted that the patient had no suspicious lymphadenopathy, evidence of extrathyroidal extension, history of neck radiation, or family history of thyroid cancer. Response options included total thyroidectomy with central neck dissection (CND), total thyroidectomy without CND, lobectomy, and active surveillance. Surgeons’ concerns about their own risks and consequences of a cancer diagnosis were assessed with the Brief Worry Scale, a validated measure of dispositional cancer worry severity in adults that has not to our knowledge been used in clinicians. We also used a validated, single-item measure of the magnitude of cancer-related worry from the National Institutes of Health—Health Information National Trends Survey. ^9,10

The 8-item Clinician Maximizer-Minimizer scale was an optional measure included at the end of the survey to assess the extent of medical care that physicians tend to favor with their patients. ¹¹ The concept and measurement of minimizing and maximizing was originally described in patients. ¹² The clinician version is based on previous patient-related work. ¹¹ Response options were on a 7-point Likert scale, with higher scores corresponding to more maximizing tendencies (range 8–56). Because the scale has previously only been used or tested in non-surgeon clinicians and has not been used or validated in surgeons, we assessed the measure’s internal consistency using Cronbach’s alpha. Of note, this scale is different from previous analyses of surgeons’ minimizing-maximizing tendencies from our group. ⁸ This scale has 8-items and is validated for clinicians, while previous work utilized an unvalidated, single-item measure.

For analysis, participants were categorized into terciles based on their responses to the Maximizer-Minimizer scale. The highest scoring tercile (“Maximizers”) was compared with the two lower terciles by Student’s t-tests, chi-square, ANOVA, and logistic regression. This method of analysis was selected because no standard exists for this scale and previous publications using the original patient version of the Minimizer-Maximizer scale utilized terciles. ¹³ The distribution of responses was also skewed toward maximizing. Because we hypothesized a priori that surgeons with maximizing tendencies would have a greater propensity to recommend more extensive surgery, a one-tailed t-test was utilized with the standard p < 0.05 threshold for significance. The survey was not designed or powered to detect a difference between worry and Minimizer-Maximizer scores. The one respondent who recommended active surveillance was excluded from analysis. To estimate generalizability and examine response bias, participants were compared with nonrespondents (n = 47) for whom basic demographic and practice data were available.

Results

Of the 149 surgeons who completed the entire survey (response rate 67.1%), 34.9% recommended total thyroidectomy with or without CND, and 65.1% recommended lobectomy. The Table depicts participants’ demographics. Overall, the medical Maximizer-Minimizer scale had an average score of 24.6 (SD 6.8). There were no differences between surgeons’ sex, age, race, annual thyroidectomy volume, specialty training, or practice setting by their Maximizer-Minimizer classification (Table 1). Participants who recommended total thyroidectomy with or without CND had significantly higher Maximizer-Minimizer scores than those recommending lobectomy (25.9 ± 7.2 vs. 23.8 ± 6.4, p = 0.03). Those classified as maximizers also had more cancer-related worry on both the single-item and Brief Worry Scales (p = 0.02 for both; Table 1). The item on the Brief Worry Scale that was different between Minimizers and Maximizers stated, “I worry about my health because of my chances of getting cancer” (2.4 [SD 1.3] vs. 2.9 [SD 1.5], p = 0.01). Nonrespondents were similar in sex (19.1% female) and specialty (63.8% general surgery trained).

Medical maximizing tendencies were consistent across all items in the scale (Table 1). The two items with the greatest differentiation between Maximizers and Minimizers were, “It is important to treat disease even when it does not make a difference in survival,” and “Doing everything to fight illness is always the right choice.” Meanwhile, the item with the least discrimination was the only item that is reversed scored, “When managing a patient’s health issue, my preference is to wait and see if the problem worsens or progresses before treating it.” The overall Cronbach’s alpha was 0.72, which increased to 0.76 if the one reverse scored item was removed. On logistic regression controlling for age, sex, race, specialty training, practice setting, and annual thyroidectomy volume, maximizers were more likely to recommend total thyroidectomy with or without a CND (OR 2.4, [CI 1.01–5.55], p = 0.047). The Hosmer–Lemeshow test for deciles of fitted risk values is 8.46 (p = 0.39), suggesting acceptable fit of the model.

Discussion

This study is the first to our knowledge to utilize the Clinician Maximizer-Minimizer scale in surgeons. Our results demonstrate that surgeons with higher medical maximizer scores are more likely to recommend total thyroidectomy than lobectomy. Those with higher scores also had more personal cancer-related worry. Specifically, they were more worried about getting cancer someday and about their health because of their chances of getting cancer. The finding that surgeons’ medical maximizing attitudes may influence their recommendation for thyroid cancer is consistent with previous studies showing that maximizing attitudes in physicians (non-surgeons) are associated with more aggressive testing and antibiotic use. ¹¹

Surgeons’ tendencies toward medical utilization and personal cancer-related worry likely represent significant barriers to adopting a thyroid-conserving approach in low-risk thyroid cancer with either hemi-thyroidectomy or active surveillance. Notably, in this cohort, medical maximizing tendencies remained significantly associated with operative recommendation even when controlling for other factors that have been associated with recommending total thyroidectomy, such as surgeon volume and practice setting. ⁸ Unfortunately, we did not ask and could not control for personal cancer history or family cancer history.

When examining the results of our study, it is important to consider that surgeons’ medical utilization attitudes may interact with the attitudes and beliefs of patient with thyroid cancer who often have high levels of thyroid cancer-related fear and worry. While the chosen extent of surgery by a maximizing surgeon and maximizing patient is easy to predict, the influence of maximizing surgeons on minimizing patients (and vice versa) is less clear. Surgeons’ beliefs about patients’ preferences and expectations are a particular area where decision-making conversations between maximizing surgeons and worried patients may catalyze the choice for a more extensive approach, as has been seen in interviews with clinicians about active surveillance. ¹⁴

A limitation of the scale used in this study is that the clinical significance of the differences observed in Maximizer-Minimizer scores between surgeons is uncertain. The finding that this identifiable attribute is associated with operative recommendations is hypothesis-generating. We have established that maximizing tendency is a measurable attribute that appears to be associated with clinical decision-making, but should be examined in larger and more diverse surgeon populations across multiple decision types. With Maximizer-Minimizer measurement, the single reverse-scored question may have muted this association. Because the scale was optional, participants may have quickly completed the 8-items and not noticed the wording difference of the reverse-scored item.

Surgeon attitudes towards cancer in general presents another challenge in de-escalating care for thyroid cancer. In this study, surgeons’ tendencies for medical maximizing were associated with cancer-specific worry. Our previous work showed that surgeons who prefer a total thyroidectomy for their own treatment (if hypothetically diagnosed with a small PTC) are more likely to recommend total thyroidectomy, a finding that may be underscored by medical maximizing tendencies. ⁵ Interviews by our group with surgeons similarly revealed beliefs such as, “Any potential for cancer to develop or spread is unacceptable.” ¹⁰ The indolent nature of most low-risk PTC is incongruent with the natural disease course of the majority of cancers and prevailing inclination towards “maximal” treatment.

Future work is needed to elucidate whether the association between maximizing attitudes and recommendations are disease-specific or constitute a pattern of behavior across disease states. Medical maximizing-minimizing tendencies represent one of potentially many unmeasured surgeon characteristics that may explain persistent patterns of over-diagnosis, over-treatment, and over-screening. Surgeons may benefit from awareness of how their own tendencies influence their surgical recommendations in patients with low-risk thyroid cancer. Interventions involving strategic education, audit-feedback, and coaching may be beneficial in helping surgeons understand and adjust their practices.