Program of Excellence
How endocrine surgery became a world-class practice
The four surgeons behind Yale Medical Group’s high-volume endocrine surgery practice are: Robert Udelsman, MD, MBA, Julie Ann Sosa, MD, MA; Sanziana Roman, MD; and Tobias Carling, MD, PhD.
The four surgeons behind Yale Medical Group’s high-volume endocrine surgery practice are: Robert Udelsman, MD, MBA, Julie Ann Sosa, MD, MA; Sanziana Roman, MD; and Tobias Carling, MD, PhD.
When patients learn that they may have endocrine cancer, the first thing they want is an exquisitely skilled surgeon who is well-versed in up-to-the-minute techniques. Then they notice how efficient and well-organized the practice is, the ease with which they can get an appointment with their doctor and whether the staff is warm and caring.
When Robert Udelsman, MD, MBA, arrived at Yale 10 years ago as chief of surgery, these criteria drove his vision of a highly sophisticated endocrine surgery program, one that would be recognized as a model center of excellence. It’s a goal the endocrine surgery team has clearly achieved. While other Connecticut hospitals remain flat in numbers of endocrine surgeries performed, Yale-New Haven Hospital’s numbers are soaring, with patients referred from competing hospitals as close as Boston and traveling places as far away as China, Israel and Saudi Arabia.
“We do it better, we do it faster and we have a particular interest in minimally invasive approaches to endocrine disease. We offer a set of procedures and innovations that other hospitals do not,” said Dr. Udelsman. “Thanks to all of these things, the program has dramatically expanded its patient volume. I think it’s pretty clear that we are now the largest endocrine program in the United States and possibly in the world.”
Specialized endocrine surgery centers with high volumes are associated with improved clinical outcomes. Between 1996 and 2010, endocrine surgeons performed 7,319 procedures at Yale-New Haven Hospital. Udelsman, along with Sanziana Roman, MD, chief of endocrine surgery; Julie Ann Sosa, MD, MA; and Tobias Carling, MD, PhD, together perform about 1,000 procedures a year. For many of these surgeries the cure rate is as high as 98 percent, and complication rates for all procedures are very low.
Perfecting sophisticated techniques
“Thyroid cancer in general has pretty good outcomes, and if you are a patient seeing a high-volume surgeon at a center of excellence, chances are good that you can rest assured,” said Dr. Roman, who has been at Yale since 1999, when she was chief resident. “All of our endocrine surgeons are high volume, so our patients have a better chance at a minimally invasive option, the recurrence rates are lower, the complications will be minimal, there is less pain and scarring and there is a faster recovery.”
The four surgeons are continually improving upon such techniques as laparoscopic adrenal surgery and what have proven to be highly successful minimally invasive approaches to primary hyperparathyroidism surgery. The latter involve removing a parathyroid adenoma, then testing parathyroid hormone (PTH) levels in the blood; if levels have dropped, the surgical team knows it has completely removed the source of the excess PTH production. Yale Medical Group endocrine surgeons have reduced the wait for blood test results to 12 minutes by bringing the laboratory machine and technicians to the surgical area.
“Now, because we’re so busy, we’ve identified a room next door where we can literally hand the sample out the window,” said Dr. Udelsman. “We run three operating rooms simultaneously, and we’re probably the only hospital in the world that will have a lab like this outside of the rooms.”
The four surgeons also interact with Yale Medical Group’s pediatric endocrine surgeons. Christopher Breuer, MD, and Scott Rivkees, MD, have created one of the largest pediatric thyroid programs in the United States. Young patients also benefit from the collaborative interactions of pediatric endocrinologists, surgeons and anesthesiologists. The results have been demonstrated by improved surgical outcomes that minimize tissue trauma.
Focus on respectful relationships
In adult endocrine surgery, Patricia Donovan, RN, MBA, who came to Yale with Dr. Udelsman from Johns Hopkins, works closely with referring physicians and provides pre- and postoperative education or patients and families, which is essential to positive clinical outcomes. “I give all postop patients my home phone number,” Donovan said. “Patients are usually very respectful about it. They will call me at 10 at night only if something is really bothering them.”
The endocrine staff assists out-of-towners with hotel accommodations and a schedule that allows them to complete their treatment through the final postop visit within a week.
Likewise, the surgeons work hard at building respectful relationships with other specialists. “When you talk about a center of excellence, it really encompasses the excellence of all these interlocking specialties that take care of a patient as a whole,” said Dr. Roman. “It takes a bit of work in cultivating the relationships, and we work on that on different levels.”
Every Friday, the group hosts a conference where they discuss cases, exchange ideas and share information with a diverse group of people from throughout Connecticut, including specialists in such areas as medical endocrinology, nuclear medicine, radiology and pathology. “It has expanded significantly and is very popular, because people like the content and collegiality. If I get a referral from a doctor in Hartford, it’s probably from someone I’ve met personally,” Dr. Roman said.
Endocrine surgeons do not practice in isolation. The surgeons are fortunate to collaborate with dedicated Yale Medical Group endocrinologists, including Elizabeth Holt, MD, PhD, and Silvio Inzucchi, MD, as well as several groups of talented community endocrinologists.
Other collaborators include Leslie Scoutt, MD, a diagnostic radiologist who performs neck ultrasounds and biopsies, and David Cheng, MD, PhD, from nuclear medicine. Endocrine surgeons also work closely with pathologists, including Constantine Theoharis, MD, and Manju Prasad, MD, who was recently named director of the Endocrine, Head and Neck Subspecialty Program in pathology.
Passion for research
In addition, Dr. Sosa works closely with medical oncologist Hari Deshpande, MD, directing six promising advanced endocrine oncology clinical trials for patients with advanced thyroid cancer or adrenal cortical cancer, with the support of the Yale Cancer Center and collaborators in medical and radiation oncology, radiology, pathology and endocrinology. The two doctors are awaiting FDA approval this year for at least one drug they’ve been testing.
“There are some patients who come to Yale hoping to get surgical procedures, but they are deemed to have locally advanced or metatastic cancer and are not appropriate candidates for surgery,” said Dr. Sosa, who joined the practice after training with Dr. Udelsman at Johns Hopkins University School of Medicine. “These patients are not turned away from Yale. They are kept in the system, and the clinical trials offer them hope when at most facilities they would not be given any hope.”
In addition, Sosa and her colleagues take pride in their productivity as far as the number of studies and manuscripts they produce, in outcomes analysis, cost-effectiveness and decision analysis, meta-analysis and surgical education research. “We do survey work and large administrative and clinical database reviews looking at practice patterns. What we are trying to do is identify predictors of the best outcomes, based on patient and provider characteristics. With health care reform going on and really revolutionary changes in the health care system, we are trying to collect and study data on how endocrine surgery should be performed in this new marketplace. I think this is very timely right now.”
Eye toward the future
Tobias Carling, MD, PhD, who completed his residency and fellowship at Yale School of Medicine, decided to practice with Yale Medical Group partly because of the opportunity to collaborate with Richard Lifton, MD, chair of the Yale School of Medicine genetics department.
“We’re the only research group in the world that has been able to develop genomewide, genetic analysis of endocrine tumors,” said Dr. Carling, director of the Yale Endocrine Neoplasia Laboratory. “Understanding the molecular pathogenesis of endocrine tumor diseases will improve diagnosis and surgical and medical therapies, especially for endocrine cancers where surgery fails and there is no other effective treatment.” Understanding what genes are involved will help us develop additional therapies.”
Specifically, Dr. Carling is studying the mutations responsible for papillary thyroid cancer, which can be difficult to diagnose. A year ago, Yale’s endocrine surgeons, in collaboration with their cytopathology colleagues, joined a handful of practices to make testing for the BRAF mutation part of their clinical routine for papillary thyroid cancer patients. When a patient tests positive for BRAF, the doctor has 100 percent confirmation of the papillary thyroid cancer diagnosis and can make precise surgical recommendations.
Meanwhile, the four surgeons have been working on another mission: preparing new endocrine surgeons and researchers to carry their mission into the future. In the last eight years they have worked with 25 medical students, seven general surgery residents and four Robert Wood Johnson clinical scholars, as well as several junior faculty members. Six fellows have launched endocrine surgery careers in other states. Said Dr. Roman, “We’re sort of planting these seeds, and that is creating a sense of community on a national level.”
