Surgeon- and Practice-Directed Interventions to Reduce Overtreatment of Low-Risk Thyroid Cancer

Importance: Overtreatment of low-risk thyroid cancer (LRTC) exists worldwide, with many patients unnecessarily undergoing total thyroidectomy. Effective surgeon- and practice-directed interventions to reduce overtreatment are needed. Objective: To identify barriers to and facilitators of implementing surgeon- and practice-directed interventions aimed at reducing total thyroidectomy for LRTC. Design, Setting, and Participants: This qualitative study, conducted between June 1, 2024, and February 28, 2025, used a focused ethnography that included semistructured interviews of 19 thyroid surgeons and site visits to 7 community and academic practices where thyroidectomy is performed. Main Outcomes and Measures: Participants ranked 6 potential interventions for reducing overtreatment of LRTC and identified implementation barriers and facilitators. Verbatim transcripts were analyzed using thematic analysis to identify the most acceptable aspects of the interventions. Ethnographic field notes provided context for interview results. Results: The 19 participants were predominantly male (13 [68.4%]), with a mean (SD) age of 46.6 (8.2) years. Participants' opinions on the usefulness of the proposed interventions differed. However, when asked to explain their intervention rankings, participants' reasoning for why they preferred particular interventions followed similar patterns. These patterns led to 3 key themes for the development of an effective intervention: (1) thyroid cancer is complex (a one-size-fits-all approach would not allow for nuanced decision-making); (2) although participants recognized the value of an intervention, they believed interventions were not appropriate for their own practice; and (3) surgeon professional identity can impact practice change, resulting in either reluctance toward practice change or motivation to change. Barriers to implementation observed during site visits were associated with differences in the clinic environment (eg, completing clinical demands, physical infrastructure) and across staffing and staff interactions (eg, presence of trainees, patient-surgeon interactions). Conclusions and Relevance: In this qualitative study of thyroid surgeons, key factors were identified for the development of an intervention for reducing overtreatment of LRTC. Participants' assessment of proposed interventions indicated a successful intervention must be seen as useful, surgeons may be motivated through performance feedback, and the intervention must fit well into the existing surgical workflow. Results demonstrated that an acceptable and effective intervention in this setting may take many forms as long as the intervention considered both behavior change and the end user.