“Do something you love, and you will never work a day in your life.” Confucius

It is no secret to people, especially physicians who know me, that I love the thyroid. My wife lovingly refers to me as a thyroid nerd. Professionally, there is nothing better than helping someone with a complicated thyroid problem. One of the cases very early in my medical school clinical years was a fascinating patient with untreated Graves disease. She was sick as sick can be and in the ICU. The short version of the story is that she made it and I had the good fortune of seeing her as an outpatient during a different clinical rotation the following year. I knew then that I wanted to be a thyroid doctor.  With the aim of staying at the same location for fellowship, I interviewed for residency programs so that I could participate and learn with the fellowship program at that institution while I was still a resident. I wanted and still desire to be the best thyroid doctor that I can be.

At my first job post-fellowship, I quickly learned that I needed to perform my own ultrasounds on patients. I had referrals for thyroid nodules from primary care doctors when there were no nodules on ultrasound at the time of biopsy. Outside recommendations to biopsy the wrong nodule based on risk factors and/or appearance of the nodule. Patients have been told they probably have thyroid cancer prior to referral when they actually have a self-resolving condition called subacute thyroiditis and didn’t have any nodules on my ultrasound examination. A patient with a neck mass outside the thyroid bed turned out ultimately to be lymphoma. I still get referrals like this as of 2021, and will probably continue to get them through the rest of my career. There are subtle, and all too often not-so-subtle differences almost every time when I compare my images to an outside study, especially if it was not done by another Endocrinologist. But why does this happen, and so frequently?

Ultrasound, as the name implies, is an imaging method that uses high-frequency sound waves to produce images of structures within the body. Most people are familiar with ultrasound from the perspective of Obstetrics and fetal ultrasound. Same test, no pain, no radiation, and you won’t glow in the dark. There are two things that make ultrasound a unique imaging modality.  First, they are operator-dependent, meaning the quality of the study is only as good as the person performing the exam. Any center or technician can get a high-quality chest X-ray, but this is definitely not the case with ultrasound. 

Second, it is a real-time study, to get a full and proper evaluation the examiner should review the imaging in “real-time” (ie. as the images are being taken). The overwhelming majority of ultrasound studies performed in the community are obtained at imaging centers or at a hospital where a technician takes still pictures and then forwards them to a radiologist to be “read”. This process of one person taking still images, and another interpreting them, is in part how you get the above examples and is in my opinion how things get missed or misinterpreted. Neither the technician and certainly nor the radiologist, know anything about the medical history of the patient and also does not know or understand much clinical thyroidology. And certain artifacts in the imaging, shadow, calcification, or sometimes just incomplete imaging (cervical nodes!!!) are lost when you only have still images to review. There just is no substitute for a trained specialist standing over the patient and performing the ultrasound examination.

So how do you know that the doctor you will see for your thyroid performs their own ultrasounds? Look for ECNU (Endocrine Certification in Neck Ultrasound) when looking for a thyroid doctor. Endocrine Certification in Neck Ultrasound (ECNU) is a professional certification in the field of neck ultrasonography for physicians who perform consultations and diagnostic evaluations for thyroid and parathyroid disorders through both diagnostic ultrasound and ultrasound-guided fine-needle aspiration (UGFNA). If a clinician has the ECNU professional credential you can be assured a physician-guided ultrasound will be performed by the same doctor that will manage all aspects of your thyroid care, including what will be covered in the next post, the thyroid biopsy.