BackTable ENT & Allergy

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Julie Wei, president of the American Society of Pediatric Otolaryngology, discuss how lifestyle medicine can resolve common chronic pediatric ENT complaints.

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SHOW NOTES

First, Dr. Wei explains the “milk and cookie disease”, a condition she coined that relates to a triad of symptoms in children that include chronic cough, nasal congestion, and rhinorrhea. In her practice, she noted that consuming dairy and sugar products close to bedtime was directly correlated with the triad of symptoms. Thus, she emphasizes that diet is the main pillar in lifestyle medicine in children.

She then explains her general workup for pediatric patients. She notes that pediatric ENT patients often have multiple complaints, so it is helpful to categorize each as chronic or acute. She always asks how many total ounces of milk the child consumes in a day, the type of milk, and the timing of dairy consumption. She has noticed that excess consumption of sugary beverages, yogurt products, and flavored milk have correlated with increased ENT complaints in children. However, Dr. Wei emphasizes the importance of educating parents about a diet of moderation instead of judging or shaming them. Dr. Wei notes that in teenagers, sleep hygiene is even more important and that eating is tied to emotions and mental states.

She encourages pediatric ENTs to share previous patient stories and to be familiar with the American Academy of Pediatrics guidelines. Other techniques for family counseling include: prioritizing key changes for a short duration and giving specific action items. She also explains how she created a pilot study and discovered that increased sugar consumption correlated with increased inflammatory cytokines.

Finally, she discusses her published books, blog posts, and online courses about the importance of lifestyle medicine in pediatric ENT.

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RESOURCES

“A Healthier Wei” by Julie Wei

https://www.drjuliewei.com/pages/a-healthier-wei

Dr. Julie Wei’s Blog

https://www.drjuliewei.com/blogs/news

Dr. Julie Wei’s Online Courses

https://drjuliewei.mykajabi.com/

In this episode of BackTable ENT, Dr. Gopi Shah discusses a lean approach to pediatric airway foreign body aspiration with Dr. Wolfgang Stehr, a pediatric surgeon and medical director of surgery at Presbyterian Healthcare in Albuquerque.

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SHOW NOTES

First, the doctors discuss the typical presentation of a pediatric patient who has aspirated an object. They agree that the most common scenario is a toddler choking on a nut, but older kids can also be affected. Dr. Shah notes that although severe aspiration cases can result in respiratory distress, most patients often look fine upon arrival to the ER. For this reason, an experienced clinician should listen for whistling sounds from the bronchi or the lack of breath sounds. Because X-rays can fail to visualize the object, witnessed history of a child choking is very important to consider. Differential diagnoses include reactive airway disease, asthma, pneumonia, and a viral URI.

Next, Dr. Stehr discusses how he implemented the lean process improvement system into the foreign body aspiration bronchoscopy procedure at his hospital. He was motivated to develop a more efficient process after realizing that the most difficult part about a bronchoscopy was putting together the equipment. The lean system is built on the principle that there needs to be a correct order for standardized steps in a procedure in order to reduce waste and train staff more efficiently. He used the “5 S’s” to organize the equipment in the ENT cart, which stands for: sort, set an order, shine, standardize, sustain. Additionally, he gives tips for physicians wanting to start their own quality improvement programs, such as including staff in decision making, having the most resistant stakeholder in the room first, prioritizing the case of patient safety, and inviting collaboration between different specialties when appropriate. He mentions that it is helpful to have a lean expert guide the quality improvement process in the beginning; eventually this third party consultant will train an internal employee to manage the lean process themselves. He also discusses the kaizen workshop, in which his team broke down a process, evaluated each step, and put it back together in a more efficient way. PDSA (Plan, Do, Study, Act) is another helpful framework he recommends.

Finally, he discusses how he measured the efficacy of his lean intervention. He used surrogate measures of time and success, which included watching techs and nurses assemble bronchoscopy equipment while timing them and seeing how many drawers they had to open to gather all the materials. Although he had favorable results, he emphasizes the importance of always being open to new ideas for improvement.

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Amal Isaiah, a pediatric otolaryngologist at the University of Maryland, discuss how to apply to US residency programs as an international medical graduate (IMG) and the unique challenges applicants may face during the process.

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/FnL1R4

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SHOW NOTES

First, Dr. Isaiah recaps his medical journey, which took him from India to the UK for a PhD, and then to the US for residency and fellowship. Then, he explains what IMG applicants can do to strengthen their applications before applying. He emphasizes the importance of making connections to the American programs through doing research work. These positions can be obtained through cold calling and emails, but he notes that there are also tenures and society fellowships available. Unfortunately, many of these positions are usually unpaid. Dr. Isaiah recommends that international medical students pursue postgraduate training in their home country and spend 5-6 years in the United States doing research before applying to US residency programs. There is a less common, alternative way to match into residency by first completing an unaccredited US fellowship program and then applying for residency.

Dr. Shah and Dr. Isaiah also discuss board exams for IMGs, which include Step 1, Step 2, and Educational Commission for Foreign Medical Graduates (ECFMG) certifications. They agree that letters of recommendation and personal statements are important. Dr. Isaiah recommends that IMG applicants read US applicant essays and have their mentors look over their essays for language and grammar revisions. Finally, the doctors discuss the different types of visas that are needed for IMG residents and attendings (i.e.- H-1 visa, J-1 visa) and differences between visas, sponsorships, and green cards. He notes that the process of obtaining a visa has been made more challenging by the COVID-19 pandemic.

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RESOURCES

ASPO Fellowships

https://aspo.us/page/fellowshiplisting

Dr. Isaiah’s LinkedIn Profile

https://www.linkedin.com/in/amal-isaiah-a6a71b6/

In this episode of BackTable ENT, Dr. Gopi Shah, Dr. Ashley Agan, and Dr. Sarah Bowe discuss new developments in the ENT residency match process as well as advice for future applicants.

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/aXEKIr

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SHOW NOTES

First, the doctors explain new policies in the match process. In 2015, the merging of osteopathic and allopathic accreditation systems began, which led to a single accreditation system combining osteopathic and allopathic accreditation in 2021. In 2022, the USMLE Step 1 exam switched to a pass/fail system from a numerical scoring system. The doctors note that although Step 1 scores used to be an application filter, research has shown that there is no correlation between scores and success during residency. Dr. Bowe notes that many programs deemed it necessary to filter using Step 1 scores because residency applications take a long time to read through. Additionally, standardized test scores do correlate well with board passage rates. Dr. Agan mentions that programs may use Step 2 scores as a replacement for Step 1 scores, leading some applicants to feel conflicted about having a Step 2 score before submitting their ERAS application. However, there have not been set Step 2 metrics for filtering applicants yet.

Next, the doctors discuss reading through applications from a program perspective. Dr. Bowe explains that bigger programs have bigger faculty, which means more application readers are available. Some programs will set unique filters to screen for IMG applicants or career goals. Then, she discusses the use of the new signaling program, an initiative that distributes applicants a certain number of tokens to indicate their programs of interest. Signaling can equalize the playing field for applicants who do not have a home ENT program or do not have the resources to do as many sub-internship and away rotations as they would like. Additionally, signaling may serve as a surrogate application cap for programs.

Finally, the doctors explain other parts of the residency application, such as letters of recommendation, research, and gap years. Because almost every ENT applicant is listed as “above average” on the standardized application, Dr. Bowe emphasizes the importance of the narrative sections of letters. Additionally, many programs allow additional space on the application to let students explain more about their background and hardships. Dr. Bowe concedes that research is important on an application, but it depends on the resources of each applicant’s home institutions as well as their non-academic priorities, like part-time jobs. Additionally, in her opinion, a gap year to do research should only be taken if the applicant is aspiring to be a clinician scientist. Dr. Shah emphasizes the importance of taking a gap year because of personal interest, not for a stronger application. Finally, Dr. Agan speaks about differences between in-person and virtual interviews. There are cons of virtual interviews, such as interview hoarding and lack of interpersonal and environmental connection, but benefits include lowering expenses and environmental impact.

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RESOURCES

Head Mirror Website

https://www.headmirror.com/

National Otolaryngology Interest Group

https://www.headmirror.com/noig

ENT in a Nutshell Podcast:

https://podcasts.apple.com/us/podcast/headmirrors-ent-in-a-nutshell/id1504305051

In this episode of BackTable ENT, Dr. Julie Wei brings Taymi Santiago, a human resources partner, about the process and benefits of taking a leave of absence.

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SHOW NOTES

First, Santiago recounts why she chose a career in HR, which gave her the ability to support others. She explains various reasons for taking a leave of absence, such as personal illness or illness of loved one, maternity/paternity leave, bereavement, education, adoption/foster care, care of elderly parents, and many more. She notes that physicians often ask for a leave of absence when their situation is already dire and there are no other options. Dr. Wei adds that many physicians may feel guilty for feeling like they have abandoned their patients and burdening their colleagues.

Next, Dr. Wei and Taymi discuss the basics of taking a leave of absence. Dr. Wei notes that HR may have negative connotations for physicians. However, Santiago explains that HR departments deal with behavioral issues and conflict management, but help with much more than just employee relations. Generally, a leave of absence is considered to be 12 weeks within 12 months that can be taken off in a continuous or fragmented pattern. They also discuss the various types of leaves that are available, such as short term leave, long term leave, and FMLA. One distinction Santiago makes is the difference between in-house versus third party leave management. For companies that outsource third parties to manage leave of absence paperwork, employees may miss out on company-specific benefits due to a lack of knowledge. For this reason, she recommends that physicians know the contact information of HR personnel at their own company.

Dr. Wei and Santiago also emphasize the two most important aspects of a leave of absence, which are job protection and wage benefit replacements. Finally, they end the discussion by discussing the harmful consequences of not prioritizing physician wellness.

In this episode of BackTable ENT, Dr. Julie Wei discusses navigating disability insurance as a physician with Dr. Stephanie Pearson, a former OB/GYN who started her own personal insurance brokerage firm.

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SHOW NOTES

First, Dr. Pearson shares about her struggle with disability. Early in her career, she suffered a traumatic injury that led to the development of a frozen shoulder and ended her clinical practice. Her group disability insurance did not cover work-related injuries, and she had to sue in order to receive her worker’s compensation insurance. She did not feel like she was properly educated about insurance policy and was promptly terminated from her OB/GYN job after her medical leave was over. Her emotional recovery was challenging, but she found support from her spouse, children, and dog. She eventually found her identity outside of her role as a physician, which helped ease her guilt of being a financial burden on her family.

Her personal disability journey motivated her to co-found a personal insurance brokerage firm with an insurance broker. PearsonRavitz was started five and a half years ago and has nationwide clients, the majority of whom are medical professionals. She frequently gives online and in-person lectures about the importance of buying disability insurance to residents and new attendings. Dr. Wei agrees and compares working in a surgical subspecialty to physical labor, as repetitive motions may increase injury risk.

Both doctors agree that standardized education for residents and medical students about disability insurance is needed. Some common myths that Dr. Pearson debunks the myths that group insurance benefits are adequate, healthy doctors do not need insurance coverage, and residents cannot afford disability insurance. Finally, the doctors end the episode by discussing unique health concerns of female surgeons, such as Infertility risk and delivery complications.

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RESOURCES

PearsonRavitz

https://pearsonravitz.com/

In this episode of BackTable ENT, Dr. Julie Wei speaks with Marshall Gifford, an expert in financial physician well-being, about benefits of financial planning and financial tips for residents transitioning into independent practice.

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SHOW NOTES

First, Gifford explains that the transition from residency to independent practice is a window of opportunity for earning compound interest, even for physicians with debt. He explains that investment will help physicians earn money from having money, so they can stop trading more hours for dollars. In his opinion, the benefit of financial advisors is to help people take action and engage in more complex financial discussions. He notes that blogs, like The White Coat Investor, can be helpful supplements to financial advising.

Dr. Wei also inquires about the intersection of physician burnout and poor financial wellness. Gifford confirms that from his personal experience as an advisor, physicians who are financially stressed often feel stressed at work as well. He motivates graduating residents to save 20% of their paycheck, because the average debt for residents is $200-400k. Next, Gifford moves onto discussing common financial mistakes that physicians make; some physicians do not understand the economics of their decision, leading them to take out more loans than their salaries can sustain. Dr. Wei agrees that delayed gratification can be a challenging principle to practice, especially as trainees see their peers in non-medical careers prioritizing expenses other than paying off their debts. Gifford also shares financial pearls, such as setting up a system of automated saving from paychecks and consulting a financial advisor before big purchases, in order to prioritize expenses. He also recommends that physicians maximize their 401k, even if they have debt, and to enroll in life and disability coverage. He recognizes that finding the right financial advisor can be difficult, as many certifications for financial advising exist. However, he believes that experience of the individual matters more than certifications. He encourages physicians to have a general conversation about physician-related financial concerns, such as asset protection in lawsuits, with a potential financial advisor in order to assess knowledge and skill set. Additionally, Gifford touches on divorce and advises both parties to keep legal costs to a minimum and to consider prenuptial agreements.

Finally, he lists four actions that residents can take now to establish financial wellness: understanding their debt, setting up an emergency fund, protecting their income, and maximizing their Roth IRA accounts.

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RESOURCES

White Coat Investors Website

https://www.whitecoatinvestor.com/

BackTable ENT Episode 53: Financial Basics from the White Coat Investors

https://www.backtable.com/shows/ent/podcasts/53/financial-basics-from-the-white-coat-investor

Real Life Financial Planning for the New Physician by Todd D. Bramson and Marshall W. Gifford

https://www.amazon.com/Real-Life-Financial-Planning-Physician/dp/B09HJ3Y791/

In this episode of BackTable ENT, Dr. Julie Wei speaks with Dr. Gita Pensa, an emergency medicine physician, about her journey to becoming a physician coach.

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SHOW NOTES

After enduring a 12 year malpractice lawsuit, Dr. Pensa explains why she chose to become a physician coach focused on helping physicians maintain their wellness through malpractice lawsuits. She started out by creating her own podcast to release 11 episodes about malpractice litigation basics. Once she realized her podcast was beneficial to many physicians, she started accepting speaking engagements and monetizing her skillset as a coach. To Dr. Pensa, physician coaching is not therapy for litigation. She doesn’t ask about details of the case that have happened, but she does help her clients reflect on the thoughts and feelings that impact their actions and reactions to their cases.

Additionally, the doctors discuss Dr. Pensa’s client distribution in terms of sex and specialty. They also reflect on the relationships of malpractice attorneys with physician coaches. Although some attorneys may push back because of privacy concerns, some attorneys include Dr. Pensa on the team. She always tries to frame physician coaching as a wellness aspect of litigation period, not a substitution for legal advice. Finally Dr. Pensa ends the episode by talking about rising physician suicide rates and physician disillusionment.

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RESOURCES

Dr. Gita Pensa’s Website

https://doctorsandlitigation.com/

Doctors and Litigation: The L Word (11 podcast episodes)

https://doctorsandlitigation.com/podcast-2

BackTable ENT Episode 42- Physicians and Litigation: The L Word

https://www.backtable.com/shows/ent/podcasts/42/doctors-litigation-the-l-word

The Upside of Stress: Why Stress Is Good for You, and How to Get Good at It by Kelly McGonigal

https://www.amazon.com/Upside-Stress-Why-Good-You/dp/1101982934

In this episode of BackTable ENT, Dr. Shah and Dr. Agan discuss turbinate hypertrophy, turbinate reduction, and empty nose syndrome with Dr. Jayakar V. Nayak, associate professor of otolaryngology at Stanford University.

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SHOW NOTES

First, Dr. Nayak gives an introduction to nasal obstruction, which may be present in patients presenting with congestion or a “stuffy nose”. Common causes of nasal obstruction include a deviated septum, nasal polyps, large adenoids in children, and turbinate hypertrophy. There are three sets of turbinates, and the inferior turbinates are located in the nose. The function of turbinates is to filter and warm incoming air. The majority of airflow happens in the lowest one third of the nose around inferior turbinates and base of middle turbinates. Turbinate hypertrophy is one of the most common causes of nasal obstruction. Dr. Nayak also notes that the same level of obstruction can affect individual patients differently.

Next, he explains his workup for patients with turbinate hypertrophy. He always asks about specific symptoms the patient is experiencing, being sure to analyze both the right and left nasal cavities. He also inquires about their current nasal regimen (i.e. use of sprays, moisturizers, ointments, gels, etc.), past surgeries, past trauma to the nose, and their breathing goals. Then, he performs an endoscopy on everyone in order to examine the anterior nasal cavity of the native nose before administering decongestant. If he observes turbinate hypertrophy, he will apply topical decongestant and observe if the patient’s symptoms are mitigated. He avoids using decongestant spray because they may irritate patients’ throats.

Dr. Nayak recommends a basic nasal spray regimen in all his patients with turbinate hypertrophy as a first line treatment. Benefits of nasal saline include clearing out mucus and drawing out fluid from tissues to reduce turbinate hypertrophy. Nasal steroid sprays like Flonase work well but other prescription sprays also exist. He notes that tolerance and side effects are usually rare, but possible reasons why medication might have to be changed or discontinued. Combination rinses are also available for patients with additional symptoms, such as allergies. If the conservative medical approach fails, he will move onto turbinate reduction surgery.

Next, he discusses a complication of turbinate reduction, which is empty nose syndrome (ENS). ENS occurs when too much tissue in the nose has been resected, leaving a massively open nasal cavity. Patients experience a wide variety of symptoms, such as difficulty breathing fully, nasal crusting, cold or burning air rushing into the nose, and congestion. Symptoms are assessed using the SNOT 22 score; a score above 11 on a scale of 0-30 indicates a possible ENS diagnosis. Dr. Nayak also explains his in-office blinded cotton test technique to accurately diagnose ENS.

Finally, Dr. Nayak discusses his turbinate reduction technique to reduce the probability of ENS. He only reduces the turbinate size while keeping shape and contour of the bone. He believes that a gradual and conservative reduction is better than a quick and excessive one. He also notes that there needs to be more standardization of turbinate reduction procedures worldwide and data on which techniques are best for preventing ENS as a postoperative complication.

In this episode of BackTable ENT, Dr. Shah and Dr. Agan talk about in-office management of salivary stones and tips for sialolithotomy.

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CHECK OUT OUR SPONSOR

Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, Dr. Agan discusses the typical patient presentation of sialolithiasis, or salivary gland stones. Sialolithiasis patients have swelling and pain in their salivary gland when eating. Sialadenitis, or inflammation of the gland, may come first, but it is also possible for sialolithiasis to be discovered on incidental imaging. In either scenario, salivary stones are benign, and the most common gland affected is the submandibular gland. Dr. Agan usually gets CT imaging and uses ultrasound as an alternative if the patient prefers. Next, she discusses her physical examination of the gland. She uses her loupes and a headlight during bimanual palpation to find the stone in the gland. She observes saliva flow as well and assesses how comfortable a patient is with oral manipulation in order to gauge their candidacy for an in-office procedure. The ideal stone for an in-office sialolithotomy is a hard stone close to the punctum. For infected stones that elicit pus and inflammation, she sends patients home Augmentin or clindamycin for 10 days before performing the sialolithotomy.

Next, Dr. Agan discusses her in-office procedure for sialolithotomy. With the patient in supine position, she uses hurricane spray on gauze and puts the gauze on the floor of mouth before injecting local lidocaine at her incision site, which is directly on top of the stone. She uses an 11 blade and keeps holding stone while taking it out to avoid losing it in the mouth. She notes that posterior stones are not good for in-office procedures, as it is close to important landmarks, such as the lingual nerve. After she removes the stone, she uses a small volume of saline irrigation to flush out the duct. Then, if the patient is able to tolerate it, she performs a sialodochoplasty, a procedure in which she sutures to create a new formal opening from the gland to the oral cavity. She notes that this procedure may require more lidocaine injection and surgeons will have to distinguish between lumen of duct and normal oral tissue.

Finally, she covers her postoperative care regimen. She does not prescribe routine antibiotics unless there was an infection discovered during the procedure. She has no diet restrictions for her patients, but notes that acidic or sour foods may make the incision burn. She recommends Tylenol or Motrin for pain and follows up with her patients in 1-2 weeks after the procedure.

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RESOURCES

BackTable ENT Ep. 25 Sialendoscopy with Dr. David Cognetti:

https://www.backtable.com/shows/ent/podcasts/25/sialendoscopy