Status of thyroid surgery-related medical disputes in China

Introduction

Thyroid cancer has increased in incidence year on year due to the enhanced sensitivity of physical examinations and the popularization of diagnostic methods. According to the global data released by the World Health Organization (WHO), the annual new cases of thyroid cancer rank seventh and fifth among all types of cancer in overall cases and cases among females respectively (1-3). According to a report released by the China National Cancer Center in 2024, thyroid cancer has shown significant fast-growing incidence rate in both genders, ranking third in incidence rate among malignant tumors (4-6). Based on the differences in the origin and differentiation of tumors, thyroid cancer can be classified into papillary carcinoma, follicular carcinoma, anaplastic carcinoma, and medullary carcinoma, among other types (7,8). Despite its rising incidence, thyroid cancer, particularly the differentiated type, has not increased the corresponding risk of death, with patients surviving for a long time after curative treatment. The main treatment strategies for thyroid cancer include operation, with some patients with differentiated thyroid cancer requiring thyroid-stimulating hormone suppression therapy or iodine isotope treatment (9). The top hospitals in China report a 5-year survival rate of 98.5% and a 10-year survival rate of 94.9% (10), which is comparable to the data from developed countries.

Surgical operations can lead to a series of complications, with common complications including hypoparathyroidism, nerve damage (recurrent laryngeal nerve, external branch of the superior laryngeal nerve), postoperative hemorrhage, and lymphatic leakage, among others. With the improvement in the quality of life of the population, a growing number of patients or families have concerns regarding the absolute benefits of thyroid surgery, that is, whether surgery can achieve a good prognosis and ensure a better quality of life. Once patients experience irreversible complications after surgery, this may adversely affect their quality of life and also impose a long-term burden on family and society. Consequently, a massive number of medical disputes arise from thyroid surgery each year, adding to the economic and psychological pressures experienced by patients, doctors, and society. This issue has been investigated in other countries and regions (11-13). Since 2010, researchers in Europe and the United States have examined and reported upon the issue of nerve damage after thyroid surgery using various databases. Moreover, in 2020, a Korean study involving 35 dispute cases discussed the legal issues caused by postoperative complications. In recent years, the doctor-patient relationship has become a more prominent social issue as medical standards have risen. This has been especially acute in populous countries such as China, where limited medical resources and nearly saturated treatment models have made medical disputes a particularly prominent social issue.

The modes for handling medical disputes in China mainly include negotiation and resolution between the patient and the medical staff, mediation by a third party (Medical Dispute People’s Mediation Committee), and administrative mediation (with patients filing complaints with health administrative departments, which then investigate and handle the case). If these methods fail to resolve the issue, or if either party is dissatisfied with the mediation outcome, the dispute can be taken to court through legal avenues. Regrettably, there is currently no searchable data or records available for the mediation of cases in China, and there is no corresponding literature available for the statistical analysis of the litigated cases. Therefore, we conducted a retrospective analysis of medical disputes arising due to thyroid surgery, with a focus on the litigated cases that could be retrieved and analyzed. This is the first study of its kind examining the current situation of medical disputes after thyroid surgery in China and analyzing the existing social issues. We believe this subject is worth exploring, as our findings can provide insights into identifying methods for resolving conflicts and avoiding potential legal and medical risks. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-24-448/rc).

Methods

We retrospectively analyzed 198 dispute cases related to thyroid surgery adjudicated between 2010 and 2022 in China. All cases were retrieved from the China Judgments Online website (https://wenshu.court.gov.cn) (14), a publicly accessible and searchable database, which has been in operation since July 2013. Except for special circumstances as stipulated by law, the legally effective judgments, rulings, and decisions of the Supreme People’s Court of China are published on this website, making it the largest database of legal documents in China and the world. As of February 23, 2022, the China Judgments Online had a total of 129,892,617 documents, with a total number of visits reaching 81,102,249,836.

Our keywords for searching the database were “thyroid” and “surgery”, which yielded 358 related cases. Before being included in this study, each document was carefully reviewed to ensure that the disputes were indeed caused by complications or contradictions arising from thyroid surgery. Ultimately, 198 cases were included (Figure 1). Specific data were collected from each case, and statistical analysis was performed on the corresponding data. The case materials retrieved are available to the public and have had the personal information of the parties involved anonymized. As the study solely used data from a public database and was conducted in accordance with the Declaration of Helsinki (as revised in 2013), it was considered exempt from approval by the Central Ethics Committee.

Figure 1 Flowchart on the selection of dispute cases.

The documents contain information on the background of the dispute, the plaintiff’s allegations, the defendant’s statements, and the court’s decision, etc. We collected basic information of each patient (such as age and gender), disease-related information (preoperative and postoperative diagnoses, type of surgery), and judicial information (type of defendant, litigation process, trial results, and compensation amounts). We analyzed the plaintiff’s accusations of malpractice against the defendant from two aspects: issues related to treatment and issues related to communication.

Statistical analysis

Data analysis and figure production were conducted using GraphPad Prism version 9.0.2 (GraphPad Software, Boston, MA, USA).

Results

We used the keywords “thyroid” and “surgery” on China Judgments Online and retrieved a total of 358 legal case files. After screening, a total of 198 cases involving disputes arising from thyroid surgery were included in the analysis. The characteristics of the patients in the dispute cases are summarized in Table 1.

Female patients (74.2%) and middle-aged and younger individuals (under 60 years old) (58.6%) were predominant. More than half (52.0%) of the preoperative diagnoses were benign lesions. The years with the most frequent disputes from surgeries were those within the period spanning 2011 to 2015 (51.0%). There were fewer cases in the earlier years, and there seems to be a decreasing trend in recent years (Figure 2).

Figure 2 Annual distribution of dispute cases.

In terms of regional distribution, the cities where most disputes occurred were Shandong (11.6%), Guangdong (11.1%), Shanghai (7.6%), Beijing (6.6%), and Jiangsu (6.6%), with the majority of regions being in the eastern part of China (39.9%). These areas are all provinces and cities in China with a dense population and a developed economy, where medical resources are also more concentrated. This may be related to the economic development of China during this period, with an increased awareness of health check-ups among the public, leading to a greater frequency of diagnosis and surgical treatment of a large number of thyroid diseases. In recent years, there has been a reduction in the number of excessive surgeries due to increased public awareness. Moreover, the reduction in complications and disputes may be related to the advancement and maturity of surgical techniques, such as the widespread application of nerve-monitoring technology (Figure 3).

Figure 3 Regional distribution of dispute cases.

All disputes involved hospitals as the defendants, with tertiary hospitals accounting for the vast majority (84.8%). This is related to China’s medical system, where the qualifications for performing thyroid surgery are more concentrated in large public hospitals, while lower-level hospitals and private hospitals have difficulty in carrying out these types of surgeries on a large scale due to limitations in conditions and technical proficiency.

Thyroid surgeries were predominantly open surgeries (95.5%), of which total thyroidectomy with lymph node dissection accounted for 78.3%. Regarding the actual pathological results, benign lesions accounted for 59.6% of cases, and the rate of consistency between postoperative and preoperative pathological diagnoses was 88.9%. The main causes of disputes were nerve damage (29.8%), parathyroid function damage (29.8%), disagreement over the scope of resection (11.5%), death (9.6%), other organ system complications (5.5%), and hemorrhage (5.1%) (Table 2). Multiple surgeries in the thyroid area accounted for 13.1% of complications and disputes.

Among all cases, 63.6% were adjudicated at the first instance, 34.4% at the second instance, and 2.0% at the third instance. In terms of judicial outcomes, the distribution of degree of defendant culpability was as follows: full responsibility (100%), 4.0%; primary responsibility (more than 50% but less than 100%), 47.5%; equal responsibility (50%), 15.2%; secondary responsibility (more than 20% but less than 50%), 14.1%; minor responsibility (less than 20%), 12.1%; and no responsibility (0%), 7.1% (Figure 4). The average expected compensation amount from the patients was Chinese Yuan (CNY) ¥577,000, while the actual average compensation awarded was CNY ¥248,000, representing 43.0% of patients’ expectations. The highest mean compensation amounts in disputes were the following: hemorrhage (CNY ¥680,000), lymph fistula (CNY ¥524,000), tracheoesophageal injury (CNY ¥466,000), other organ system complications (CNY ¥381,000), and death (CNY ¥316,000) (Figure 5). There was no criminal liability in any of the cases examined.

Figure 4 Distribution of defendant’s degree of culpability according to complication type.

Figure 5 Distribution and proportion of different complications and average compensation amount. CNY, Chinese Yuan.

As seen in Figures 4,5, in cases of disputes following thyroid surgery, the defendant was found to bear equal or greater responsibility in 66.7% of the cases, with an average compensation amount of CNY ¥248,000, representing 43.0% of the patients’ expected compensation. In the vast majority of cases tried in court, the hospital, as the medical entity, bore the greater share of responsibility. We also observed that the actual compensation amount was far less than what the patients expected. The highest mean compensation amounts were for hemorrhage (CNY ¥680,000), lymph fistula (CNY ¥524,000), and tracheoesophageal injury (CNY ¥466,000). These complications, although infrequent, are more severe when they occur and result in higher costs.

The cases were finally adjudicated on an average 3.8 years after the surgery, with only 10.6% being resolved in the same year, and 21.2% being resolved after more than 5 years, with the longest lawsuit lasting 45 years before a judgment was issued. Regardless of time and location, the occurrence of disputes and the type of complications always drain the energy and financial resources of the parties involved.

Discussion

Thyroid surgery is still one of the main treatment methods for thyroid disease at present. Although surgical techniques are becoming more refined, it is inevitable that due the modern pursuit of a higher quality of life, varying degrees of postoperative complications will occur, leading to various medical disputes. In recent years, there has been increased research attention on the improvement of prognosis in the treatment of thyroid diseases but little discussion regarding the related postoperative dispute events (15). Given China’s standing as most populous country in the world, there are limited medical resources for diagnosing and treating its massive number of patients. Despite the progress made in the field of thyroid surgery in China over the past years, hardly no studies have been conducted that have reviewed and reflected upon the issue of disputes caused by postoperative complications. The postoperative dispute events from major medical centers are often minimized or suppressed under the ethos that “domestic disgrace should not be publicized”. In recent years, with the progress in China’s medical standards and philosophy, along with the initiation the China Judgments Online, the public has an enhanced capacity to obtain data on these doctor-patient conflicts, and we can better reflect upon and learn from previous case histories to develop the medical industry. To this end, we conducted this study, the first in China to analyze and report on the current status of medical disputes following thyroid surgery, with the hope of addressing the legal and medical issues in thyroid surgery.

In the analyses of the data, several prominent observations emerged. There was a higher proportion of young patients and patients with benign lesions, with the majority of cases occurring in economically affluent areas. We speculate that under conditions of better expected survival, a greater number of medical disputes will emerge. Against the specific background of China’s health care system, more disputes occurred in the early 2010s, with tertiary hospitals persisting as the institutions where these cases most frequently occur. Open surgery accounted for the majority of disputes, and as the scope of surgery expands, it is likely to result in even more complications and legal cases. As a vulnerable group in the medical relationship, patients are more likely to be respected and protected by the law when irreversible damage or long-term psychological hardship occur postoperatively. We even found that in some cases, compensation would be more or less awarded to due humanitarian considerations regardless of culpability. However, in the analyses of the overall compensation amounts, the actual compensation was less than half of the patients’ expectations, and in the vast majority of cases, the expected compensation amount of patients was not fully met. Undoubtedly, protracted litigation leverages economic and psychological hardship upon individuals, families, hospitals, and society.

From the data, it is evident that the most common causes of disputes following thyroid surgery were nerve damage and parathyroid function impairment, which is consistent with the findings from other developed countries (11-13). As China continues to develop and the quality of life of its citizens improves, it may be that the adverse effects of thyroid surgery, such as discomfort from hypocalcemia and hoarseness, on the physical and mental health of the population will become less tolerable and more keenly felt. This may lead to a decline in the quality of life, and the expansion of the surgical scope will increase such risks. Strategies for the protection of parathyroid glands include intraoperative identification and protection of their blood vessels from injury. To improve the survival rate and secretory function of autotransplanted parathyroid glands, it is recommended to transplant parathyroid glands with some attached fat tissue. The “1+X+1” principle for parathyroid protection should be followed, and the effective identification of accidentally removed parathyroid tissue should be ensured which can be done using techniques such as frozen section pathology or immunocolloid gold test papers, and adjustments should be made to the surgical resection scope (16-19). On the other hand, the protection of nerves has long been a key issue in thyroid surgery. Since the 19th century, surgeons have been exploring and researching nerve protection in thyroid surgery. The injury rate of the recurrent laryngeal nerve has decreased from initially 29.5% to 8.9–12.9%. In 1966, Shedd and others introduced intraoperative neuromonitoring (IONM) technology into thyroid surgery, which further reduced the intraoperative injury rate of the recurrent laryngeal nerve, better avoided damage to the external branch of the superior laryngeal nerve, and allowed for a higher probability of nerve protection in complex surgeries, such as reoperations with adhesions and substernal goiters (20-26). However, according to literature review and our center, in the early postoperative period, even when these measures are applied, nearly half (10–50%) of the patients have some degree of perturbation to vocal cord function and voice quality upon laryngoscopic reexamination despite no visible nerve injury during surgery and intact neuromonitoring signals (27,28). These impairments may be related to intubation, surgical manipulation, and other factors. Although patients may gradually recover from these effects over time, for professionals dependent on their voice, such as singers, teachers, and lawyers, these can seriously impact their future life and work. In addition, nerve monitoring also has guiding significance in treatment decision-making after signal loss following the resection of one lobe, which was first proposed in the guidelines of 2011 (29). If the signal is lost on one side, staged surgery can be performed to prevent bilateral vocal cord paralysis and subsequent tracheotomy due to nerve damage (30,31). This also underscores the importance of strictly adhering to the indications for surgery and the extent of resection.

In China, with the increasing awareness of physical examinations, the detection rate of thyroid diseases has risen. However, we also recognize that not all diseases, such as benign nodules and microcarcinomas, require surgical treatment. Rash surgeries may increase the risk of complications and are more likely to lead to disputes. Standardizing preoperative fine-needle aspiration and gene testing may better differentiate benign and malignant lesions, assess the risk of metastasis, and make sounder decisions on whether surgery is necessary as well as the surgical resection scope. This is one of the strategies to reduce medical disputes. For low-grade malignant lesions, observation can be chosen instead of rash surgery. For benign lesions with compressive symptoms, treatments such as aspiration with sclerotherapy or radiofrequency ablation can be considered as alternatives to traditional surgery (9,32-38). Naturally, with the introduction of novel technologies, the operator’s learning curve may lengthen, and data from studies with larger sample sizes and the development of better guideline standards and national oversight are required. These procedures should be carefully conducted in qualified centers to potentially avoid medical injuries.

The dispute cases included in this study were more often caused by traditional open surgery, which may be due to the fact that in the time period we examined, traditional surgery was more commonly performed in China, with fewer centers being capable of performing minimally invasive excisions. However, with the advancement of surgical techniques in recent years and the greater demand for aesthetic outcomes among patients undergoing surgery, a growing number of centers are adopting minimally invasive approaches for surgical procedures. Endoscopic thyroid surgery is one of the major advancements in thyroid surgery that has occurred over the past 20 years, with common methods including endoscopic thyroidectomy through different approaches (transoral, transaxillary, or subclavian) and robotic thyroid surgery. Longer surgical routes involve a greater risk of dissection and injury, the introduction of a wider array of instruments implies a longer learning curve, and the nonexposure of wounds is associated with a greater complexity in managing complications. There remains a lack of randomized controlled studies and long-term follow-up data for evaluating the relative benefits of minimally invasive surgery and conventional surgery. Therefore, the application of minimally invasive surgery to thyroid diseases must strictly adhere to the indications and be performed by experienced surgeons, in compliance with the principle of safety first, completeness second, and cosmesis third (39-42). Patients who already have a good prognosis after minimally invasive surgery may nonetheless file a medial judicial dispute if their expectations are not met. Therefore, it is possible that the proportion of such cases among future disputes may significantly increase, which also reminds us to be more cautious in our daily medical practice. In addition, as it pertains to the demand for cosmesis, we have also observed that scarring in the neck area is a common risk of traditional thyroid surgery. Although according to our statistical data, these issues have not become a more common cause of medical litigation, related clinical disputes nonetheless occur. In addition to the aforementioned alternatives in surgical approach, other methods, such as improved techniques, injection of botulinum toxin immediately after thyroid surgery, low-dose postoperative radiotherapy, and administration of steroidal drugs to the postoperative incision area, have been attempted. These methods are widely used in the field of plastic surgery and often involve higher costs, but they cannot guarantee the complete suppression of scar proliferation. The means to balancing the patient’s expectations, medical expenses, and minimization of doctor-patient conflicts remains an issue that must be considered in clinical practice (43-45).

Admittedly, the data from the China Judgments Online has certain limitations, with the information focusing more on the legal aspects of the cases, there is often a lack of basic patient and medical information. Moreover, although the included cases cover most provinces and cities in China, they are limited to more severe instances. It is believed that many more disputes have occurred, including many that have been privately mediated by hospitals, that remain outside the current legal case retrieval system. Moreover, this study represents a preliminary retrospective exploration in this field. We are well aware of its limitations and look forward to subsequent prospective studies that can further clarify the related issues. It is hoped that through the joint efforts of scholars in China and around the world, the surgical treatment of thyroid diseases can become safer and more standardized.

It is important to note that medical disputes are not the same as medical accidents. Medicine is not a cure-all, and economic compensation in cases does not equate to financial reparations. The principal trends in medical disputes in China are as follows: (I) there is an increasing number of cases year on year. The volume of medical complaints is high, requests for medical technical appraisals numerous, and the number of disability assessments growing, with media involvement also intensifying. (II) Medical institutions are more frequently losing court cases. The new “Regulations on the Handling of Medical Accidents” (formulated to correctly handle medical accidents, protect the legitimate rights and interests of patients, medical institutions and their medical personnel, maintain medical order, ensure medical safety, and promote the development of medical science) adopts the principle of a reversed burden of proof, leading to an increase in the number of situations in which hospitals are unable to provide the necessary evidence. (III) The compensation amounts awarded are becoming larger. The ultimate outcome of medical disputes often involves demands for financial compensation from hospitals. Whenever there is a situation unfavorable to the hospital, especially when it is unable to provide evidence, patients and their families may demand a high amount of compensation. (IV) There is greater difficulty in achieving a resolution. The causes of most medical accidents and disputes are complex, and the relevant laws and regulations have not yet fully matured. Moreover, society generally views patients as a vulnerable group that should be given special protection, making the resolution process particularly challenging for medical institutions. (V) The social impact is growing. Especially in cases where patients’ demands for high compensation are not met, they may repeatedly file complaints with health administrative departments, judicial departments, and the media. Coupled with the fact that some media outlets lack medical knowledge and may engage in speculative reporting without understanding the facts, this can cause significant damage to the reputation of hospitals.

Conclusions

The current situation of thyroid-related medical disputes in China is complex and has varying degrees of impact on patients, doctors, and society. In summary, the characteristics are as follows: medical disputes related to thyroid surgery primarily stem from nerve and parathyroid damage; there are significant discrepancies between the expected and actual compensation amounts; the lengthy resolution times highlight the need for enhanced communication regarding surgical risks and a more efficient medical dispute resolution process.

To enhance the standardization and safety of surgical treatment for thyroid diseases, a joint effort from the medical community, the legal sector, and society at large is necessary. This includes improving the quality of medical care, refining the relevant laws and regulations, and enhancing the public’s medical literacy. Furthermore, it is crucial to recognize the difference between medical disputes and medical accidents, as well as the limitations of medicine and the nature of economic compensation.

Acknowledgments

We would like to thank Lei Liang for his invaluable assistance in refining the figures for this manuscript.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-24-448/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-24-448/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-448/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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