BackTable ENT & Allergy

In this episode of BackTable ENT, Dr. Varun Varadarajan speaks with Michael Johnson, a business lawyer, about evaluating and negotiating physician employment contracts in private practice and academic settings.

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SHOW NOTES

First Michael explains how hiring a contract lawyer can help physicians understand their employment contracts and prioritize their negotiations. He notes that there are pros and cons to all of these contracts, but they are not written to be read very easily by people without legal backgrounds to understand. He adds that although local lawyers may have intimate knowledge of the geographic area, finding a physician contract lawyer is most important. Then, he explains the “trinity of physician contracts”, which are the three most important factors of employment: compensation, obligations, and exit strategy. Additional clauses include non-compete clauses, non-solicit clauses, and malpractice tail expenses. He explains that accepting a base salary does not prevent future salary negotiations.

Next, Michael talks about private practice contract considerations, such as business risks, salary growth, the potential of selling the practice, private equity, and partnership tracks. He advises delaying partnership track if buy-in is too high or if the physician has different financial priorities. Advantages to partnership include more decision-making, autonomy, and ancillary revenue. Other factors he advises to research before signing a contract include payer mix distribution and the distribution of patients. He briefly explains what hospital recruitment agreements are. Although they may offer more competitive salaries than a stand alone private practice contract, they are often more complicated to understand.

Then, he discusses academic medicine contracts, which can offer different opportunities than just increased profits. He warns physicians to be aware of changes in administration and department turnover, as these events can lead to unplanned and unwanted shifts in obligations. He also notes that through the RVU system, teaching and administrative duties are not compensated. Thus, one of his goals is to protect physicians from being overworked.

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RESOURCES

Michael Johnson’s Website:

https://www.michaeljohnsonlegal.com/physician-contracts/

Michael Johnson’s Instagram:

https://www.instagram.com/physiciancontracts/

Episode 45- Private Equity: Savior or Existential Threat?

https://www.backtable.com/shows/ent/podcasts/45/private-equity-savior-or-existential-threat

In this episode, host Dr. Bryan Hartley interviews head and neck surgeon and entrepreneur Dr. Alex Langerman about the story of his startup, ExplORer Surgical and his idea generation advice for physician-innovators.

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SHOW NOTES

Dr. Langerman starts by describing his journey into head and neck surgery and his University of Chicago research lab, where he conducted research over improvements in the operating room (OR) setting. The idea to make the OR more efficient stemmed from a conversation with a medical student who wondered why so many operating tools were opened and laid out, but never used. This question led him on a tour of different ORs around the country, where he learned that a lot of his colleagues shared the same frustrations about inefficiencies in the OR. When he returned to his institution, he visited different surgical departments and integrated their concerns into a roadmap of aspects that could be improved upon.

We also discuss the value of bringing in non-physicians who have fresh perspectives. Dr. Langerman sought feedback and help from business and design students, which eventually led to the incorporation of his company, ExplORer Surgical, and a pitch at the New Venture Challenge Competition. While he worked on communication with surgeons about minimizing waste in the OR, his co-founder, Jennifer Fried, led the effort to find investors. The company’s inflection point occurred when they shifted the focus away from healthcare institutions and towards medical device companies. The ExplORer Surgical app became a playbook that device companies could use to educate operators and ensure that their devices were being implemented in the exact way that they were intended to be used, thus ensuring consistent outcomes and minimizing complications. It also offers a way for sales representatives to virtually teleconference into the OR and guide operators through the procedure. During COVID, this technology became incredibly useful to ensure that collaboration between the OR and medical device companies could still continue. The company was eventually acquired by GHX Medical in 2021.

Dr. Langerman encourages physician entrepreneurs to try “idea harvesting,” defined as pitching your idea to others, in the effort to see what resonates with them and learn how to improve your pitch. Additionally, finding a team of business professionals that can help run day-to-day operations is a great way to free up time and energy for further idea generation.

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RESOURCES

Dr. Alex Langerman Website:

https://alexanderlangerman.com/

New Venture Challenge Competition:

https://polsky.uchicago.edu/programs-events/new-venture-challenge/

SBIR and STTR Grants:

https://www.sbir.gov/about

Social Physics by Alex Pentland:

https://www.penguinrandomhouse.com/books/314230/social-physics-by-alex-pentland/

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Melanie Sulistio, associate dean of student affairs at UT Southwestern, talk about the importance and art of having difficult discussions with patients and medical colleagues.

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SHOW NOTES

First, Dr. Sulistio explains why the humanity in medicine is centered on a foundation of communication between patients and physicians. She emphasizes that scientific advancements cannot help society if physicians cannot communicate them to their patients. Then, she gives examples of obstacles that may make communication challenging, such as an unfortunate diagnosis, language barriers, family dynamics, biases, cultural backgrounds, and different goals and priorities of each party.

She suggests strategies to overcome these barriers, such as scheduling the appropriate length of time to share the news, checking that it is a good time for the patient to receive the news, and making sure the provider themselves are emotionally ready to share news. She encourages providers to show emotion, but not to the point that the patient has to comfort them. Dr. Sulistio also emphasizes including the support system of the patient in the discussion and evaluating what the patient understands about their condition before beginning the discussion. She warns against assuming that you know what the patient is feeling, bringing up personal experiences, and apologizing inauthentically. Body language cues are also important, such as eye contact and pulling up a chair to meet the patient at their level. She recommends speaking to the nurses, techs, and medical assistants about the patient before entering their room, as they have the most exposure to the patient everyday.

Next, the doctors discuss how to deal with language barriers and translation services. Dr. Sulistio notes that physician humility is an important aspect to these discussions, as providers should never make non-English speaking patients feel like a burden to treat. She notes that although wording may be lost in translation, physicians need to remind themselves to speak to the patient instead of to the translator.

Finally, Dr. Sulistio gives advice about having difficult conversations with medical colleagues and trainees. Before entering these discussions, she makes sure to check on her own implicit biases and emotions. She proposes the idea of compassionate assumption, or believing that other people are always doing the best they can in every scenario. In her opinion, simulation is the best method for teaching medical trainees how to navigate difficult conversations.

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RESOURCES

Dr, Sulistio’s Grand Rounds Presentation at the Mayo Clinic:

https://mssvideoupload.mayo.edu/media/Creating+a+Culture+of+Diversity+on+a+Personal+Level%2C+Navigating+Hard+Conversations/1_58oap0g7

Think Again: The Power of Knowing What You Don’t Know by Adam Grant:

https://www.amazon.com/s?k=think+again+adam+grant+paperback&hvadid=496397429222

Brené Brown podcasts:

https://brenebrown.com/podcasts/

Abraham Verghese books:

https://www.abrahamverghese.org/books/

Atul Gawande books:

http://atulgawande.com/books/

In this episode of BackTable ENT, Dr. Gopi Shah discusses microtia repair techniques with Dr. Mai Thy Truong, fellowship director of pediatric otolaryngology at Stanford University.

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SHOW NOTES

First, the doctors discuss the preoperative workup for children with microtia. Dr. Truong explains that it is very difficult to catch microtia or anotia in a prenatal ultrasound, so the diagnosis is usually a surprise at delivery. She takes time in explaining the diagnosis to the family with her co-surgeon and assesses the family’s emotions. Her follow up plan is to get the child fitted for hearing devices if needed and sets up conversations about preferential seating and FM systems in school. She will follow up with patients once every year; during these visits, she orders an audiogram and measures the length of the normal ear and chest frame. The length measurements of the normal ear help her get a sense of when the normal ear stops growing and the measurement of the chest frame helps her decide whether the rib cartilage is robust enough for surgery. She notes that ears will stop growing in length around 7-10 years of age and ear stops growing and that a chest frame size of 60 cm indicates that there is enough cartilage to make the entire ear. Once the family has decided on surgery, she orders a CT scan to learn about the temporal bone anatomy and other problems in the underdeveloped ear. Then, she works with computer programmers to create a 3D model of a mirror image of the normal ear to guide her carving during surgery.

Dr. Truong is trained to use the Firmin technique of microtia repair. This is a 2 stage procedure that involves harvesting rib cartilage and using it to carve out ear subunits. Her co-surgeon always harvests the graft from the ipsilateral rib cartilage while she creates the skin pocket where the new ear will be placed. Additionally, she explains how to avoid causing a pneumothorax and instruments needed for the rib cartilage harvest. She also emphasizes the importance of creating a harmonious skin pocket and warns listeners against manipulating the anterior blood supply of the ear by mistake. Then, she discusses how she carves the rib graft into 5 different subunits of the ear with an 11 blade and a 15 blade. She uses steel sutures to suture each part together using a particular order. Finally, she is able to put the ear framework into the skin pocket, close the incision site, and apply dressing.

Lastly, she explains her postoperative care of microtia repair patients. Her patients remain in the hospital for 3 days and receive antibiotics (Augmentin) for a week. She also obtains a chest x-ray after the procedure.

In this episode of BackTable ENT, Dr. Shah and Dr. Agan invite two comprehensive dentists, Dr. Abhishek Nagaraj and Dr. Anushka Gaglani, back to the show to discuss diagnosis and treatment of xerostomia.

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SHOW NOTES

First, the doctors explain common causes of xerostomia, which include multiple medications and comorbid conditions. Lifestyle factors, such as mouth breathing, alcohol consumption, tobacco usage, smoking, and dehydration can also contribute to xerostomia. Less common causes of xerostomia include Sjogren syndrome, chemotherapy, radiation, and radioactive iodine exposure. Then, they discuss how to perform a comprehensive xerostomia workup. Xerostomia is formally diagnosed by measuring the rate of salivary flow for 5 minutes. It can also be diagnosed through minor salivary gland biopsy, but this procedure is performed by ENTs or oral surgeons, not dentists. After taking a thorough patient history, dentists may be able to see evidence of xerostomia during physical examination through signs like fissures on tongue, halitosis, ill-fitting dentures, and angular cheilitis.

Then, the dentists explain the different treatments for xerostomia, from lifestyle changes to medications. They recommend that patients drink 60-65 ounces of water daily and brush at least two times a day. Fluoride mouthwashes and sugar-free lozenges may also help stimulate saliva production. Finally, a cholinergic medication like pilocarpine can be used if patients do not get better with non-pharmacologic intervention. Dr. Nagaraj also recommends that patients with xerostomia come in for dental cleaning four times a year instead of only twice because of their increased risk of developing dental caries. Finally, the doctors discuss how to distinguish the sensation of a dry mouth from the true diagnosis of xerostomia.

In this episode of BackTable, Dr. Bagrodia interviews Dr. William Flanary, a physician-comedian popularly known as Dr. Glaucomflecken, about lessons he has learned as a two-time testicular cancer survivor and the importance of humor in medicine.

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SHOW NOTES

First, Dr. Glaucomflecken shares about his first diagnosis of testicular cancer. During his third year of medical school he felt a lump in his testicle, which led to a quick workup, diagnosis, and a full orchiectomy. The diagnosis was emotionally difficult, as he was in his mid-twenties and healthy. He returned to comedy, a skill he had developed in high school and college, to cope with his diagnosis. This time, however, he started to practice medical-based comedy with his new experiences as a medical student. He recounts other discussions he had about his cancer, such as fertility, the possibility of chemotherapy, and active surveillance.

Four years after his first orchiectomy, he received his second diagnosis of testicular cancer during his last year of residency. He recounts feeling distraught and overwhelmed, as questions about fertility, hormone replacement, medical expenses, and postponing residency became more serious. He decided to have a full orchiectomy and testosterone replacement therapy, which solved his issues with fatigue and irritability. Additionally, his wife got him involved in testicular cancer support groups and foundations, including one called First Descents, an organization that encourages young adults with cancer to explore the outdoors. He notes that young patients are often overlooked in cancer support groups and encourages cancer patients to find their support networks outside of friends and family as well.

Then, Dr. Flanary discusses his experience with suffering from cardiac arrest in 2020, which led to his wife doing ten minutes of chest compressions to keep him alive. He reflects on this event and concludes that it taught him how to be a better physician to his patients by making sure he involves patients’ families and encouraging him to address medical insurance issues directly.

Finally, Dr. Flanary discusses how he uses humor to advocate and educate patients on social media. He notes that comedy can stimulate conversation and debate and encourages physicians to have social media presence.

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RESOURCES

Knock Knock Hi Podcast

https://podcasts.apple.com/us/podcast/knock-knock-hi-with-the-glaucomfleckens/id1659572053

First Descents

https://firstdescents.org/

In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with two comprehensive dentists, Dr. Abhishek Nagaraj and Dr. Anushka Gaglani, about common dentistry complaints and their treatments in head and neck cancer patients.

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SHOW NOTES

First, the dentists discuss the role of dental clearance before radiation or surgery initiation. Dr. Nagaraj explains that dental clearance is when dentists check for ulcers, dentures, caries, and any other issues that may bother patients from a treatment standpoint. He mentions that it is helpful for surgeons to specify which conditions they would like dentists to focus on in clearance assessments. Both dentists use a set of 5 clearance screenings and give either full or partial clearance. For minor dentistry treatments, they recommend waiting at least 14-21 days to start cancer treatment. For major dentistry treatments like root canals or wisdom teeth extraction, they recommend waiting for at least 4-6 weeks before major surgeries due to the different healing potentials of each patient.

Next, the dentists explain common side effects of radiation treatment, such as xerostomia, osteoradionecrosis (ORN), candidiasis, and mucositis. Dr. Nagaraj discusses how xerostomia can cause dental caries, which may result in a mandatory tooth extraction and ORN. He and dr. Gaglani recommend treating xerostomia with compounded mouthwashes, lubricants, xylitol, and fluoride toothpaste. They will use antifungals to treat candidiasis. For trismus, they recommend mouth stretching exercises and NSAIDs. Dr. Gaglani emphasizes the importance of upkeep dental hygiene routines in order to minimize the severity of these side effects. However, they both note that with the advent of intensity-modulated radiotherapy, less patients have complained about side effects of radiotherapy. Patients may also complain of post-radiation changes, such as ill-fitting dentures and loose dental implants due to decreased bone density and loss of osseous integration.

Finally, the ENTs and dentists speak about the importance of oral cancer screening in the dentist office. Both dentists perform a visual and tactile examination for all new patients, paying special attention to the tongue, floor of mouth, and lymph nodes. They end the episode by sharing ways how ENTs can collaborate better with dentists, such as encouraging patients to go in for regular dentist visits and specifying conditions they are concerned about during treatment.

In this episode of BackTable ENT, Dr. Gopi Shah, Dr. Walter Kutz (UT Southwestern), and Dr. Daniel Choo (Cincinnati Children’s Hospital) discuss indications and repair techniques for tympanic membrane perforation in children.

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CHECK OUT OUR SPONSOR

Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, the doctors discuss the typical patient presentation of a child with a perforated tympanic membrane (TM). Tympanostomy tubes falling out are the most common causes of this condition. Trauma and suppurative otitis media can also cause a TM perforation. The doctors emphasize the importance of taking a thorough history and asking about previous tubes, craniofacial abnormalities, the function of the contralateral ear, and recent trauma. Then, they discuss physical exam techniques to inspect the affected ear. All agree that using a standard otoscope is most useful in clinic, as the endoscope is more useful in the OR. Additionally, Dr. Choo notes that he usually streams the inspection on video monitors on the wall for kids and families to see.

Not all children with TM perforations have to undergo tympanoplasty. If there is a small perforation without hearing loss, watchful waiting may be appropriate. However, Dr. Kutz adds that if there is evidence of cholesteatoma or severe hearing loss, repair may be the best option after explaining all options to the parents. The doctors then weigh the risks and benefits of immediate TM repair versus watchful waiting and assess whether size and location of perforation matter. They conclude that the functional status of the children, evident through school performance and language development, have an important contribution when choosing a treatment option as well.

Next, the doctors discuss different tympanoplasty techniques, including different types of grafts (cartilage, fat, synthetic, etc.), ways to shape the grafts, and taking a microscopic versus endoscopic approach to the repair surgery. They also discuss common causes of failure and postoperative complications. Finally, they each explain their postoperative regimens and alternative rehab options if hearing does not improve enough after surgery.

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RESOURCES

Cook Medical

https://www.cookmedical.com/otolaryngology/

In this episode of BackTable ENT, Dr. Ashley Agan interviews Dr. Rebecca Howell, division chief of laryngology at University of Cincinnati, about her diagnosis and management of Zenker’s diverticulum.

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CHECK OUT OUR SPONSOR

Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, Dr. Howell explains that Zenker’s diverticulum (ZD) is a swallowing disorder caused by abnormal outpouching in the esophagus. ZD is only a herniation of the mucosal layers instead of all three tissue layers, so it is classified as a false diverticulum. To have a diagnosis of ZD, patients must have evidence of cricopharyngeus muscle dysfunction and congenital dehiscence. Oftentimes, these patients are in their seventh decade of life and will have problems with regurgitation. Dr. Howell also explains how to distinguish ZD from other differential diagnoses such as pure cricopharyngeus muscle dysfunction and nutcracker esophagus. She notes that a typical ZD patient will have a “rising tide”, or the ability to elicit frothy secretions as they talk.

Next, the doctors discuss different surveys used to diagnose and assess ZD severity. Dr. Howell also speaks about her current prospective study to determine risk factors and prognosticators of ZD. She explains that in general, men and women are affected evenly by this condition and that endoscopy has allowed the earlier diagnosis of ZD patients. Some important factors she always asks while history taking are: previous surgeries, the patient’s motivation for pursuing surgery, and the presence of neurologic diseases. Next, the doctors discuss different imaging modalities like flexible endoscopy, barium swallow studies, EGD, and manometry. Dr. Howell sees lots of potential in the field to develop and standardize workup for ZD diagnosis. While analyzing imaging studies, she also looks for concurrent diagnoses, such as paraesophageal hernia and hiatal hernia.

Then, Dr. Howell discusses how she counsels patients about treatment options for ZD. She frames ZD as a quality of life issue instead of a necessary surgery for everyone. If her patient does not choose to pursue surgery, she makes sure that they are aware of future red flags, such as pneumonia hospitalization and unintentional weight loss. The doctors also weigh the pros and cons of using an endoscopic versus open surgical approach. Based on Dr. Howell’s studies, there is no difference between both approaches, so surgeons should choose the method they prefer more. She summarizes her endoscopic technique, including her list of equipment and how she collaborates with anesthesia providers. Finally, she summarizes her postoperative care regimen and explains how she deals with leaks, an uncommon but serious complication of ZD surgery.

In this episode of BackTable ENT, Dr. Gopi Shah, Dr. Romaine Johnson (UT Southwestern), and Dr. Alex Chiu (University of Kansas) discuss health disparities research and the Health Equity Collaborative.

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SHOW NOTES

First, Dr. Chiu explains the difference between equality and equity. Equality is giving everyone the same resources to reach a goal, while equity is giving people different resources based on their different background and obstacles to reach a goal. Health equity emphasizes the importance of the provider focusing on interpersonal relationships and caregivers of patients, not just on their patients as individuals. Dr. Johnson explains that although there are many research studies that prove the existence of inequalities, there are not enough research studies centered on how specific interventions can reduce disparities.

Then, Dr. Chiu explains the Health Equity Collaborative, an initiative to drive more health equity research in the field of ENT across different institutions. The collaborative was started in February 2022 in Kansas City. Dr. Chiu and his team quickly realized that they did not have the adequate volume of patients needed to achieve a sizable impact, so they reached out to more ENT researchers in different cities. The collaborative uses qualitative research methods, such as the qualitative structured interview, and then formulates objective metrics to analyze the results. Future goals of the collaborative include gaining the support of societies and using their evidence to change policies and advocate for minority patients. Dr. Chiu also explains obstacles he had to overcome when forming the collaborative and the benefit of working with a diverse team.

Finally, Dr. Chiu shares how his disparity research has affected his medical practice by making him a more patient physician. He listens closer to his patients to try and understand his patients’ decisions and non-compliance before judging them. He is also inspired by research initiatives from other medical specialties.