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Surgeons who treat patients with thyroid cancer and other endocrine diseases have varied clinical backgrounds. Their training or clinical practice may be based in general surgery, oto-laryngology, head and neck surgery, surgical oncology, urology (for adrenal tumors), or endocrine surgery. Regardless of the surgeon's title, a surgeon specializing in endocrine disease has a role and responsibility far beyond the operating room. This chapter examines the general surgeon and the specialist endocrine surgeon in the context of thyroid and other endocrine surgery.

Historically, endocrine disease was a prominent aspect of the general surgeon's practice. Indeed, some of the greatest names in the history of surgery have left their mark within endocrine surgery. General surgeons including Kocher, Halsted, Lahey, Mayo, Crile, and Cope played dominant roles in the development of the surgical treatment of endocrine disease [1,2].Before the role of iodine deficiency in endemic goiter was understood, this was a common disease treated with thyroidectomy performed by general surgeons [3]. Before the 1940s, when therapeutic radioiodine and antithyroid medications were first introduced, surgery was also the only available treatment for hyperthyroid states such as diffuse goiter (Graves' disease), toxic multinodular goiter (Plummer's disease), and toxic adenomas [2]. Although Kocher

(1841-1917) is well known as the first surgeon to perform a high volume of endocrine (thyroid) procedures (Figure 11.1) [2],it was not until the 1950s that surgeons in several countries embraced the philosophy that an understanding of the physiology, embryology, and pathology of the endocrine system was an important companion to technical expertise in the operating room. Realizing that advances in knowledge and skill would accompany increased clinical experience, these early "endocrine surgeons" focused their practice on endocrine surgery as a separate subspecialty within general surgery [2].

This relatively informal stance essentially still applies today. The "specialist endocrine surgeon" remains a loosely defined term that, in the USA, has no formal definition or requirements. Although often defined by the scope of the surgeon's clinical practice, it simultaneously refers to the level of training, the extent of clinical practice for the ongoing development and maintenance of skills, the advancement of knowledge in surgical endocrinology through clinical and basic science research, and the role in educating medical students, surgical residents, and endocrine surgery fellows. The specialist surgeon exchanges knowledge and opinions at national and international medical meetings to help develop improved and evidence-based treatments as well as guidelines for the surgical treatment of benign and malignant endocrine disease. Specialist surgeons recognize the importance of a multidisciplinary approach

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Figure 11.1 Theodore Emil Kocher (1841-1917); a pioneer "endocrine" surgeon. (Reproduced with permission from Wel-bourn [2], page 16.)

and should serve as leaders in fostering relationships between the surgeon, endocrinologist, oncologist, radiologist, nuclear medicine physician, pathologist, primary care physician, and allied healthcare professionals.

Exponential growth in medical knowledge and technology has fueled the demand for advanced knowledge and skills for every disease process that general surgeons treat, regardless of what subspecialty umbrella it falls under. This advanced level of expertise is becoming increasingly difficult for a general surgeon to obtain and maintain. This chapter will evaluate thyroid and other endocrine surgery training, analyze clinical practice profiles of those practicing endocrine surgery in the USA, and depict professional aspects of endocrine surgery that separate the general surgeon or otolaryngologist who performs endocrine surgery from the endocrine surgeon who specializes in the treatment of endocrine diseases. The successful surgical management of thyroid and other endocrine diseases requires the cooperation of both general and endocrine surgeons.

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