Development and Pilot Testing of a Conversation Aid to Support the Evaluation of Patients With Thyroid Nodules

Naykky M. Singh Ospina; Diliara Bagautdinova; Ian Hargraves; Diana Barb; Sreevidya Subbarayan; Ashok Srihari; Shu Wang; Spyridoula Maraka; Carma L. Bylund; Debbie Treise; Victor Montori; Juan P. Brito


Clin Endocrinol. 2022;96(4):627-636. 

In This Article

Abstract and Introduction


Objective: To support patient-centred care and the collaboration of patients and clinicians, we developed and pilot tested a conversation aid for patients with thyroid nodules.

Design, Patient and Measurements: We developed a web-based Thyroid NOdule Conversation aid (TNOC) following a human-centred design. A proof of concept observational pre–post study was conducted (TNOC vs. usual care [UC]) to assess the impact of TNOC on the quality of conversations. Data sources included recordings of clinical visits, post-encounter surveys and review of electronic health records. Summary statistics and group comparisons are reported.

Results: Sixty-five patients were analysed (32 in the UC and 33 in the TNOC cohort). Most patients were women (89%) with a median age of 57 years and were incidentally found to have a thyroid nodule (62%). Most thyroid nodules were at low risk for thyroid cancer (71%) and the median size was 1.4 cm. At baseline, the groups were similar except for higher numeracy in the TNOC cohort. The use of TNOC was associated with increased involvement of patients in the decision-making process, clinician satisfaction and discussion of relevant topics for decision making. In addition, decreased decisional conflict and fewer thyroid biopsies as the next management step were noted in the TNOC cohort. No differences in terms of knowledge transfer, length of consultation, thyroid cancer risk perception or concern for thyroid cancer diagnosis were found.

Conclusion: In this pilot observational study, using TNOC in clinical practice was feasible and seemed to help the collaboration of patients and clinicians.


Caring for patients with thyroid nodules often includes deciding when to proceed with thyroid biopsy or monitoring with thyroid ultrasound (US). This decision is based on thyroid cancer risk, presence of symptoms associated with nodular enlargement or hyperthyroidism secondary to toxic thyroid nodules.[1,2] Additionally, the decision of how to proceed depends on the patient's preferences, values and context.[1,2] In fact, the American Thyroid Association (ATA) suggests consideration of patient factors that can affect the expected risks and benefits of a thyroid biopsy, such as high surgical risk or limited life expectancy.[2] Ideally, the end result of this process is a decision that makes sense to patients intellectually (i.e., I understand what I am doing), practically (i.e., I can do it) and emotionally (i.e., it feels right).[3]

Yet, in practice, these conversations are challenging. Clinicians often have difficulty communicating thyroid cancer risk, the risks/benefits of biopsy and eliciting patients' preferences. As evidence of the complexity of these conversations, a survey of 196 patients that had just undergone a thyroid biopsy showed that patients had a limited understanding about the thyroid biopsy outcomes.[4] In fact, one-third were not aware that their biopsy could be reported as nondiagnostic or indeterminate, and half did not know their risk of thyroid cancer. These results suggest a gap in the quality of decision making and the need to support conversations in clinical practice related to thyroid nodule diagnosis.[4]

Shared decision making (SDM) is a care approach that supports conversations between patients and clinicians about treatment or diagnostic decisions.[3] Tools that support SDM have been found to increase knowledge, accurate risk perceptions, satisfaction with the decision and the number of patients achieving decisions that were informed and consistent with their values.[5] To support SDM between patients with thyroid nodules considering thyroid biopsy and their clinicians, we developed a Thyroid NOdule Conversation Aid (TNOC). Here, we report the development of TNOC and the results of the initial (pilot) evaluation of its impact on the quality of conversation and diagnostic decisions.