Patients with very low-risk thyroid cancer are often over-treated with surgery and radioactive iodine. This study aimed to better understand patients’ and surgeons’ decision-making about treatment for very low-risk thyroid cancer that leads to overtreatment. This qualitative study of 10 patients with very low-risk thyroid cancer and 12 surgeons used semi-structured interviews and validated measures of decision preference, control, and satisfaction to characterize decision-making. The majority of patients were white (90.0%) and female (80.0%), with a median age of 47.5 years. Most surgeons were white (91.7%), male (83.3%), and endocrine surgeons (83.3%) who worked at a university or academic institution (91.7%). Patients and surgeons both preferred the patient to make the final treatment decision after considering the surgeon’s opinion. They least preferred to leave the final decision to the surgeon. Patient experiences ranged from deciding on their treatment prior to surgical consultation to a perceived lack of a choice because the surgeon only discussed one option. When asked what was most important in choosing a treatment, patients frequently discussed removing the cancer and trusting their surgeon’s recommendation. Multiple factors influenced surgeons’ treatment recommendations – most commonly clinical data and patients’ anxiety. Surgeons described tailoring their recommendation based on their own perception of patients’ level of fear and risk tolerance, but did not explicitly assess patients’ preferred treatment. When making decisions about treatment for very low-risk thyroid cancer, patients and surgeons prefer a shared model with the patient controlling the final decision. Surgeons’ recommendations appear to heavily influence the decision, but are based on the surgeon’s own perceptions of patients’ preferences, which may not be accurate. To achieve value-concordant patient-centered care, explicit discussion of patients’ preferences in relation to all treatment options and outcomes will be key.