Podcast Transcript: Identifying Parathyroid Glands: Challenges & Innovations

[Dr. Gopi Shah]
Michael, can we quickly talk about the Medtronic probe, the PTI? Is that a fluorescence or an autofluorescence technology?

[Dr. Michael Singer]
I don't want to confuse people because once you start talking about-- It's like talking to patients about thyroid versus parathyroid. They have the same word in them. Patients are like, "Wait, thyroid, parathyroid." It's the same thing here.

The device, all of these devices, they're designed for fluorescence. It happens to be that parathyroid glands have this quality, this intrinsic, what's called a fluorophore. There's something in there that almost acts like you've ejected ICG into the gland. What's important is, is that currently, currently this is very important, the device is FDA-approved for autofluorescence to help confirm something to be a parathyroid gland or not. That's what it's for.

This is where some technologies really just do it. This thing was brought into my operating room the first time, and I'm a somewhat skeptical surgeon. You have people show up in your operating room all the time with devices, technologies, and they're like, "Oh, this thing is going to change the way everything you do." You're like, "Whatever."

Then you use it and it turns the operating room purple and you're like, "Okay, so what? How does that help?" This is one of the first devices or one of the only devices that I've ever used where I used it and I was like, "Wow, this thing does what it's supposed to do and really does it pretty accurately without any-- It's not complex.

Maybe I have a comfort level like Ashley was saying, because I use nerve monitoring, maybe it was just very intuitive it's use. It really does what it's supposed to do. What I say to people is a little bit, this is when nerve monitoring first came out, and one of the issues they had with getting surgeons to adopt it is, surgeons would stimulate something, say with the nerve probe that wasn't the nerve.

They would say, "Oh, this technology stinks." They'd say, "Oh, this technology doesn't work. That's the nerve and it's not stimulating." Guess what? It wasn't the nerve. It's the same thing here. You have to be open to the possibility that as much as you do, and I'm talking about for myself, as much as I do, there are times where I'm wrong.

I'm like, "Oh yes, that--" I have residents, so I'm forced to be pretty honest because nowadays they'll call me out. Historically, you would have just sat there and afterwards we'll gone over to your resident and co-resident and be like, "This guy doesn't know what he's doing." There's times where you stimulate something and you think it's a parathyroid gland and it's just not.

You have to trust the technology to some extent, because the technology is not perfect either. It has false negatives, false positive, those kinds of things. I've used the camera-based system as well, and there's different versions of it. I think that the camera-based system has advantages too.

The camera-based system, one advantage of it, at least in its current formulation, is that it allows you to look at both fluorescence, and if you're interested in looking at vascularity, allows you to do fluorescence imaging also. I think the other big advantage of it is it gives you a global view.

This isn't like, "Oh, I'm testing this one micro area." It's assessing the whole area. If you have listeners who are actually interested in trying these technologies, I would encourage them to try both and see what they feel more comfortable with and what works in their hands. A little bit this is what I was saying before about just everyone has to know what their challenge is for anyone to say, "Oh no, no, no, the one that you should use is this."

Everyone has different challenges. You have to figure out which of these devices, if you find them helpful at all, maybe you won't find them helpful at all, but which of these devices potentially helps you address the challenges, you as the individual surgeon really are trying to deal with.

[Dr. Gopi Shah]
Would you say that it has changed the way you do thyroid and parathyroid surgery? If so, how?

[Dr. Michael Singer]
I would say the two areas that it's had the biggest impact, and maybe this is not surprising. At this point, my practice has largely, not exclusively, but it's largely become parathyroid surgery. I think that the areas that it's had the biggest impact is probably in parathyroid surgery. There are definitely instances where in thyroid surgery I find it's already made differences for me. Say, for example, in say reoperative central neck dissections, where there's a ton of scar tissue, parathyroid glands are genuinely at risk in those cases.

I think that in those cases it's already been helpful to me in certain instances. Where I could tell you it's made probably the single biggest difference is in parathyroid surgery it has eliminated, in my practice, the need for getting frozen sections. Now the reality is that I don't get very many frozen sections to begin with.

Some people use frozen sections on a routine basis. Some people use them only in challenging cases, all these other things. Even though I don't always get them, I still do occasionally get frozen sections. The way I use this technology now, it's eliminated that. I don't want to say 100%. You're right, there is nothing that we use that's 100% of the time, 100% accurate. It's eliminated that need.

One of the things that that does, particularly in more challenging cases, maybe cases of a bilateral neck exploration, is it's almost an automatic and immediate, that's the key, frozen section. One of the annoying things with frozen sections is, if you could get that result instantly, it helps you.

When it takes 25 minutes to get the result back, because it's not almost real time, it doesn't allow you to make surgical decisions as readily. You're like, "Oh, okay, now I'm going to wait for that biopsy result. I'm going to go and do something else, and then I'm going to come back to this question that I have." Whereas with this, it's like the nerve monitor in the sense that it immediately tells you.

Then you can say, "I now know I've found this gland. Let me move to the next gland." Or, "Now I've found all four glands," or however else it is. That, I think for me, it allows me to make certain surgical decisions and then moves much more quickly than I would have in the past.

[Dr. Gopi Shah]
Michael, for your parathyroid surgery, are you still sending PTH levels to have more of a functional test in conjunction with the autofluorescence technology, or are you not doing that as much now either?

[Dr. Michael Singer]
I'm not so dogmatic about the way parathyroid surgery is done. What I mean is some people, they only believe in this approach and they do this, and they do this on every single case. I'm not as much as that.

Say, for example, if I found all four glands, and I look at one of the glands with my eyes, and I'm like, "That's clearly normal," or, "That's clearly abnormal," and the rest of these glands that I've found, and I know that they're there, either on my own or because I'm using one of these devices to confirm that stuff is para, I don't get PTH levels in that case, because I know now, as we all know, as surgeons, sometimes we say, "Oh, 100%." Guess what? 100% you're not. That's not 100%. It's just not.

This is where I like it. You need to, at least a little bit try to be humble as a surgeon. Some of us are better at that than others. It's not that it's like, "Oh, I now use this and that's eliminated PTH levels." That's not the case. In those cases where maybe in the past I would have used it because I'm pretty sure the patient's cure, but I'm not 100% sure that that other thing that I found was a parathyroid gland, that then there are cases where it's just like, "I'm not going to wait now."

For example, these technologies right now, if you're doing focused parathyroid surgery, you are still obligated, at least in my mind, and I know there's some people who don't, but at least in my mind, you're really obligated to use intraoperative PTH to verify that in fact the remaining glands are not hyperfunctional. At this point, that hasn't changed.

I think if it ever is going to change, we're going to have to go back to that question of like, so should we be doing bilateral neck explorations on all patients? Should we be looking at all parathyroid glands?

[Dr. Gopi Shah]
As far as, I think to your point about time saved when you're comparing waiting for a frozen versus being able to have that instant verification that it is parathyroid, when you start talking about cost and the added cost, time in the OR is one of the most expensive items when you think about surgery. I assume that you feel like that that being able to buy back that time makes up for the cost of adding the device to the surgery.

[Dr. Michael Singer]
Yes. The first thing I would say is that I am not an economist. I'm not an economist. I actually do pay attention to cost, even though I literally have never had, say, someone from my institution come to me and say, "Oh, why are you using this?" Or, "Do you really need to--" In the practice I have, it doesn't happen that much, but I do pay attention to it.

I know that that's a real genuine issue. I, as a academic surgeon, I feel like my job is to try and help figure out, is this technology helpful? How can it be used? Really where are the benefits? To me, that's related to cost. I don't know that there's ever going to be a time that it's going to be like, "Oh, this is so amazing and it's so relatively cheap that you should be using this on every single case."

I don't know that that's ever going to happen. I think that our job as academic people is to try and help figure that stuff out and then work both with hospital administrators, but also companies to find a point where they're still willing to make it and invest that money in developing these technologies, which we want, which are good for our patients, but that's not so expensive that it prevents us really from using it.

This was where I think there is a lot of similarity to nerve monitoring. When nerve monitoring first came out, first of all, the first thing that happened was people said, "We don't have nerve injuries. They just don't happen." Pretty quickly, and this is really largely due to the effort of a few people, particularly Greg Randolph from Harvard.

People started to say, "Wait, wait, wait, no nerve injuries are actually happening. Then surgeons started to say, "Yes, they happen, but not in my hands." Then they said, "I don't really need this. It doesn't really help. It doesn't this." Then eventually people got to the point where some people were using it in some cases. "Oh, I'm going to use it in re-op cases. I'm going to use it in substernal cases. I'm going to use it in, I don't know, cancer," whatever it is.

Over time that has evolved. This goes, again, back to the cost question that's evolved to a point where now many people at many institutions, many practices use nerve monitoring and wouldn't even think of doing, say, thyroid surgery without it. It's gotten to that point.

Now, I don't know that this type of stuff is ever going to get to that same point where it's being used regularly, every single case. I don't know. Honestly, I don't think that's probably going to be the case. What I do think is that as time goes by and the technology gets better, and we figure out, "Oh, you know where it's really helpful? It's really helpful in x case, and this case, and that case," that it's going to become integrated in the way we do at least some cases.

Now, again, you still have people who are doing thyroid, say surgery out a regular basis and they say, "I don't need nerve monitoring. It doesn't help me at all." I'm sure you'll have the same thing with this. You'll have people who say," I don't ever need this." That's fine. Then you'll maybe have people who say, "Oh, you know what? I use it on every single case because I just would never feel comfortable not using it.'

I think you're going to end up getting to a point, again, where the technology is good enough, it's relatively inexpensive. That's the key word, relatively inexpensive. It's not going to be cheap, but compared to say a bad outcome or a complication, or all these other things where it's going to get to a point where people are going to start to integrate this in different ways to varying degrees in their practices.

[Dr. Gopi Shah]
As we start to round it out, just in the interest of time, I've learned a ton, especially about being forthright with myself as a surgeon. Any final pearls that you want to leave our audience with?

[Dr. Michael Singer]
Yes. It's funny because I think I would just say that one of the best things that came out of my fellowship was, I spent a lot of time with Dr. Terrace. One of the things that I learned from him is, and it's not that I hadn't learned this in residency. I had other faculty, of course, who talked about this and I saw it.

I think that one of the things this goes to your comment, you just made, Gopi, about, that he said is he really emphasized the idea of just being open to new things. Just being open to new things. He would talk about the idea of maybe you don't always want to be the first, but you don't always want to be the last. I think that that's relevant to this technology. I think it's true to all technologies.

We all know that some things come along and they're super flashy and the company may say, "This is a cure-all, it's the silver bullet for the problem." Sometimes, I'll say, for financial reasons, people run to adopt certain things. Then you also have people who are like, "I don't need that." Or, "I don't have that problem." One of the things Dr. Terrace would always talk about is just be honest, at least with yourself about how good you are at something. Can you use some help at least some of the time and then consequently say, "How do I get better?"

This goes to our conversation from earlier about the idea of average and expert. It doesn't matter what level you are. I tell this to my patients all the time. We all can get better. We can. At the point where you are saying, "I'm the world's authority on this. I'm perfect," it is time to get out. That's when you're really going to run into trouble.

I think the idea of just being open to things to just continuously try to improve both for yourself, but most importantly for our patients, I think it's applicable, again to this technology. I think it's applicable to techniques, technologies that probably go throughout all surgical and medical fields. Honestly, that was one of the best parts of my fellowship because I think it just made me think about things in a very, sometimes brutally honest way. I think ultimately that's both good for me and for my patients.

[Dr. Gopi Shah]
I love that. Continuous learning. Stay humble.

[Dr. Michael Singer]
By the way, that's the point. I imagine, I don't know, but that's to some extent the point of the podcast. Why do we do this? It's about saying, "Hey, you know what? I do a lot of this, but maybe there's something new that I can do," or, "Maybe I can do this a little bit--"

[Dr. Gopi Shah]
I don't do any of this, and I really had to research and look up things to prepare for this.

Dr. Michael: Or maybe I don't do any of this, or maybe I don't do any of this, and maybe it's good I don't do any of [crosstalk]

[Dr. Gopi Shah]
I should know how to think about it. [crosstalk]

[Dr. Michael Singer]
I don't do it. I shouldn't do any of this. That's also an important realization. I imagine that that's part of the goal of your podcast. Is to try and address people or deal with people who are saying, "Hey, what can I maybe do better?"

[Dr. Gopi Shah]
If people want to connect with you or reach out to you to discuss more, is there a good way to get ahold of you? Are you on any socials or just find you on Henry Ford Health?

[Dr. Michael Singer]
Yes. My kids will tell you that I'm a dinosaur because I'm not a social media exactly maven. I'm old school, at least what's now considered old school. You can go on our website. The best thing is just to email me. Maybe you guys can put, I don't know if you have like show notes or whatever else. The email is msinger1@ hfhs.org, that's henryfordhealthsystem.org.

I'm really happy to talk about it. If you have either interest in this or questions about parathyroid glands or parathyroid surgery, as you can probably tell, I'm a little bit of a parathyroid geek. This is a topic that I could talk about and talk about for a long time. I'm really always happy to.

I told, Gopi, the risk is if you get me on the phone and get me going, it may be a little while, but as long as you're willing to risk a little bit of more time on this than you want to, I'm really happy to always talk to people about stuff.

[Dr. Gopi Shah]
Thank you so much. This is great. Awesome. Thank you so much.

[Dr. Michael Singer]
My pleasure. Thanks guys.