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In-Office Procedures in Otolaryngology

Author Yvonne Ogrodzinski covers In-Office Procedures in Otolaryngology on BackTable ENT

Yvonne Ogrodzinski • Jan 26, 2023 • 258 hits

Anatomical treatment of the nose and throat can have a profound impact on a patient’s ability to breathe. Offering in-office procedures is one way to increase accessibility of treatment for patients while also allowing them to avoid a trip to the OR. Dr. Madan Kandula, founder of ADVENT, an ENT private practice, discusses the importance of a team-based approach to in-office procedures in the field of otolaryngology and explains how he has navigated many of the practice hurdles that are common in an office-based setting.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• In-office procedures offered by an otolaryngologist can include turbinate reduction, nasal swell body reduction, balloon sinuplasty, VivAer, and LATERA.

• Dr. Kandula built ADVENT up to 13 practice locations by focusing on nose and throat issues that can be treated in-office with a limited scope of simple, repeatable interventions. As the practice grew, Dr. Kandula and colleagues eliminated service lines that didn’t fit into the niche that they had established, including audiology services.

• Insurance authorization is a substantial hurdle to offering in-office procedures. Dr. Kandula explains that successful authorization is all about advocating for the patient’s best interest. It takes dedicated effort to push insurers to do the right thing, and ENTs should be aware of insurance challenges if they are interested in building an office-based practice.

• Establishing a team-based approach to care can help to streamline in-office procedures. As one example, ADVENT staffs a team of nurse practitioners and physician assistants that specialize in patient evaluation, allowing their physicians can focus on treatment plans and procedures.

Man undergoing in-office procedure in otolaryngology

Table of Contents

(1) Finding Your Niche of In-Office Procedures

(2) Hurdles to Offering In-Office Procedures

(3) Optimizing In-Office Procedure Efficiency with a Team-Based Approach

Finding Your Niche of In-Office Procedures

Anatomical treatment options for nasal breathing are made more accessible when offered in-office, and these treatments can have a profound impact on a patient's quality of life. In Dr. Kandula’s private practice, they offer a more limited scope of simple interventions. Focusing on a core set of in-office procedures has allowed them to optimize the way that they treat nose and throat issues, and better help patients with challenged breathing. Organizing their practice around these core service lines and utilizing a team-based approach also allows the surgeons to manage their time more effectively and focus on the in-office procedures that they are most skilled at.

[Ashley Agan MD]
You said around 2014, you zoned in and started focusing on the breathing triangle. Does that mean that you don't see ear stuff anymore and thyroid? Have you really honed in your practice where you're really just focusing on diagnoses related to breathing?

[Madan Kandula MD]
Yes. It didn't happen all of a sudden in 2014, but over time. It was a gradual recognition on my part that these issues, basically, these are the areas that I as an individual and we as a specialty are most needed. In order to step forward in these areas, it means leaving and abandoning things that I was well trained in. If you follow the story there, my wife is an audiologist. ADVENT no longer does audiology. It was a big deal, she too saw clearly the impact we were able to make. Those are important areas that do need care, but I think as it relates to issues in the area, the breathing triangle area, the nose and throat, it gets very confusing for patients to understand, where do I go to? Whether it's sleep apnea or whether I can't breathe through my nose, do I see an allergist? Do I see a primary care doctor? Who do I see? I think conceptually, on that topic, I'm very, very passionate about our specialty.

When you think about allergy as a specific example, there are general allergists and there are ENT trained allergists. Generally speaking, because we have that problem-oriented surgical mindset, we take that approach to even allergy. So I generally feel that our ENT colleagues who do allergy, they might not be as in the weeds and in the books as the general allergists, but they're likely going to give you the best chance for success.

Back to the point of, who do you see if your nose isn't working? Why would you go see somebody who can't impact the anatomy?

In fact, don't be surprised when you see somebody who can't impact the anatomy that you're never going to hear about anatomical treatment options. Even for our ENT colleagues. If you are seeing an ENT who is unable or unwilling to offer office-based treatments for anatomic issues, don't be surprised that you never hear about options for those issues, and don't be surprised if the only option you may ever hear is an OR option. Which, I'm kind of preaching, but I'd say that the breathing triangle as a concept is very simple, but it's so simple that in my opinion, it cuts to the core of where there isn't that level of clarity in our own specialty. What specialty should be more clear about the impact and the power of the nose than otolaryngologists? Nobody. That's our territory definitively, and yet, as a specialty, we have not been clear. Really, for me personally, it's just simply, I can be bothered by some of these things, but it's really more a matter of, what are you going to do about it?

I think with ADVENT and what we're trying to do is simply saying, this whole situation, there's a better way. We're not perfect and I'm not perfect, but we're going to try our hardest to help the patients out there that need us.

[Gopi Shah MD]
I know there are 13 locations. Just in the average clinic, how often are you seeing patients where you're their second, third, fourth opinion, or maybe the topic of nasal obstruction or the breathing triangle hasn't even come up, and you're like, "Wait a second, this is the elephant in the room. It's right here. This is what we need to address?" How often is that happening?

[Madan Kandula MD]
All the time. Sometimes, it's certainly patients who we're their sixth opinion. That happens. Though, frankly, with our messaging, we do a lot of direct-to-consumer marketing and just education. Frankly, for folks who have sleep apnea, I think there are many folks who are unwilling to interact with the healthcare system that's broken as it relates to the breathing triangle. As an example, if somebody thinks they might have sleep apnea and they know that their friend, Bob, and their friend, Sally, they have the CPAP thing and Bob tried it. He didn't like it. Sally, she has it, but man, that's weird, and I don't want that. Then they hear us and they just hear a different conversation, they might be willing to come in to look at those issues and look at various options that might help them versus, “You snore, You have sleep apnea. Let's slap a CPAP on your face and deal with it.” For our patients, our "why" as a practice is that we unlock potential. That's what we do on a daily basis, patient after patient. Every patient that we see who has issues in the breathing triangle is negatively impacted by those conditions in a profound way.

I think we as a specialty, I just keep going back to this concept, it is the simplest things that we do that make the most profound changes, and yet we elevate and cherish the rare sort of fascinoma, bright shiny object like, “I did this 20-hour case” and you helped one person. That's great. There's nothing wrong with that, but I think, again, for what we do at ADVENT, it's taking the most simple things. There's an elegance to simplicity and there's an elegance to being able to do something well. But simple interventions to impact profound conditions never gets old. We do have more of a limited scope because we're dealing with nose and throat issues, but we're literally dealing with the most important areas in the body. Again, when you think about some of the concepts in ENT, I don't know that we as a specialty do a good job of just sitting there and thinking about that. Why am I saying that? If you think about the ABCs. If I dropped down with a heart attack and the ambulance came in, they'd follow the ABCs, and the A is airway. The airway is ours, and the airway is your nose and throat. It's really mostly your throat in that situation, but these are profound issues, and I challenge colleagues, our colleagues in our specialties, to say, what is a more profound issue than this, than somebody who has challenged breathing?

It's not just physical issues; it creates mental issues. For us, we really try to focus on what's in front of us, but I see it all the time. We see it all the time, folks who are dejected, it's not a medical diagnosis, depressed, which is a medical diagnosis, have downstream conditions that are related to breathing triangle issues. What are those conditions? Diabetes, heart attack, strokes. You think about all the things that happen when somebody has sleep apnea that's not being treated, those are repercussions of a breathing triangle that's broken or not open. When you correct those things, it creates profound change. Again, I just go back to it, and we don't understand that as a specialty, and I guess I'm trying to do my part to just educate.

[Ashley Agan MD]
With 95% of your procedures in the office, what's your week or month like? Meaning, do you do two, three days a month in office procedures and one day a month in the OR? What's your schedule like?

[Madan Kandula MD]
My schedule is super weird because I'm only clinical one day a week at this point, so I've got this weird–

[Ashley Agan MD]
You're a physician entrepreneur right now.

[Madan Kandula MD]
Yes, exactly, but for my surgeons, it depends. It's usually a half day in the OR a week, and then when they're in the clinic, we tend to bucket it. You're doing office procedures, that's one block of work. You're doing, we call it CT clinic, which is basically patients coming in, CTs, basically treatment planning, is that part of thing, and then you're seeing post-procedure patients. Those are the big block. In-office procedures, most of our surgeons are doing those procedures. Not necessarily every single day of the week, but more days of the week than not.

We have a very process-oriented way that we'll offer those, I think the challenge for a lot of folks who are trying to do office work is that they try to reinvent the wheel every single case and you will drive yourself crazy by doing that. For us, our medical ENTs greet the patient, spray them up, place pledgets. There's that part of the work that's crucial. You've got to get that topical stuff on board early enough for it to be working. You don't need to be doing that. You could. You could choose to do that, but that's taking away from something else you could do. That's our medical ENTs. Then surgeons are coming in, doing the injections, doing the procedures, and going from there. Our surgeons do do a lot of procedures, but those procedures are almost always done in the office like we're talking about. Their work week looks nothing like I think anybody else's work week that I know of in ENT, and it's a good thing. We try to preserve their sanity. You basically allow them to intervene at the right time.

The right time is if you need to have a 45-minute conversation with a patient about treatment planning, about the nuance, then take the time to do that. Don't be looking at your watch like, "I'm now 5 minutes, I'm 10 minutes, I'm 15 minutes late." How many of us have been burned out by the death by 1,000 cuts of, "I'm always too late." It's always like, "I'm always late. Wherever I am, I'm supposed to be somewhere else," that's a horrible way to go through life. Honestly, I've been there, I've done that. I choose not to do that and our docs choose not to do that either because there's a different way.

Listen to the Full Podcast

The Future of Otolaryngology is in the Office with Dr. Madan Kandula on the BackTable ENT Podcast)
Ep 72 The Future of Otolaryngology is in the Office with Dr. Madan Kandula
00:00 / 01:04

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Hurdles to Offering In-Office Procedures

While offering in-office procedures can be beneficial for patients, there can be hurdles in navigating insurance coverage and equipment costs. Insurance authorization requires justifying the benefits of in-office procedures compared to offering the same procedure in an OR. In-office procedures can be cost-prohibitive early on. To mitigate the startup costs, Dr. Kandula suggests working with industry to secure loans or focusing on treating other patients to generate enough revenue to offset expenses.

[Ashley Agan MD]
Patients have to get used to the way you run your practice too. It starts whether it's the phone call, the call room, the check-in. It's your whole team and how you run it, so this is the practice. I wanted to ask in terms of in-office procedures, is it hard to get insurance, is it easier just to go to the OR for insurance approvals and things like that? Is it more accessible or less accessible to a patient, the in-office procedures?

[Madan Kandula MD]
That's a good question. From an insurance standpoint, it is more challenging to get approvals for office-based procedures than OR procedures. That's a truth in my opinion. For a practice like ours, this is what we do every day, and so it's the right thing for our patients, to offer office-based procedures, and so we take that burden on ourselves. We are the ones who will fight with insurance companies and fight with our colleagues who are sitting on the wrong side of that equation, in my humble opinion, from denying authorizations, those sorts of things.

We'll take that fight and that fight is, to me, we're a very mission and purpose-driven organization. Part of that is understanding that it's the right thing to offer these services to our patients. Just because it's a bit harder for us to do that doesn't make it less right. It just means that somebody's got to do a little bit more work and we're willing to do that. Yes, just to state it bluntly, with our practice, it would be easier for us. Insurances would have an easier time of it if we had ASCs in every metro area that we were in and we were just driving those cases into the operating room. There'd be less hassle about authorization than there is for office-based procedures, which is insane when you think about it at face value. Long story short, I think for our colleagues who are looking at doing office procedures, it is an uphill battle. I think that it's a shame but it's true. There's a learning curve, which is significant. It's a whole different beast getting your practice to be capable of doing office procedures well. Part of that gets to the authorization. There's a lot of hurdles there that you have to decide that you're going to want to clear before you even go down that road.

I would advise people listening to take that seriously and make sure like, "Yes, this is something I want to do," and "Yes, I'm willing to fight the battles that need to be fought and so forth and so on." Because if you aren't clear with yourself on that, you're going to run into those barriers and it's just going to stop you in your tracks.

[Ashley Agan MD]
Can you give us some specific hurdles that you went through, whether it was clinic 1, clinic 7, clinic 13?

[Madan Kandula MD]
Let me go just very granular and basic. Pre us doing office-based procedures, we didn't. The most extensive procedures I did in my office before balloon sinuplasty became available to do in the office would've been scopes, biopsies, ear tubes in adults, stuff like that. The typical stuff that ENTs do in the office. Those are very discrete kinds of things. To do an in-office nose and sinus procedure, there's an entire numbing process that's just more elaborate than what we need for scopes and things like that.

All of those things, getting at that point my PAs on board, getting my office staff on board, but just the actual logistics of we're going to take time to do something and learn how to do it while we're doing it, people don't want to do that. There's that. Then from an authorization standpoint, when balloon sinuplasty first had CPT codes that allowed it to be done in the office, there were many insurance carriers that didn't cover it at all. Anthem was one specifically for many years that didn't cover it. Now, the challenge for me at that point was thinking about, when I'm sitting in front of a patient, "Gosh, is this an Anthem patient? Anthem doesn't cover in-office procedures. Is that something I should bring up, that they're not going to cover it?" Those sorts of things. Then it's just simply doing the annoying work of justifying our medical decision-making to our, at the end of the day at this point, it is our colleagues, it's our ENT colleagues who work for insurance companies. I'm calling them out, but I'd say the system is so unpleasant to deal with. When I say the system, I'd say the authorization system. You're taking a three-dimensional patient with three-dimensional issues and you're boiling it down into not even two dimensions, you're boiling it down into bullet points, and you're having some bean counter, look at those bullet points to decide if this is authorized or not authorized. Then you're having one of our colleagues look over the shoulder and say, "Yes, that's what it ought to be." Then you have a surgeon and a patient that are simply trying to achieve an outcome. Then everybody's like, "It's hard. I don't know what's going on." I know exactly what's going on, and again, we're guilty on this one. I'm going down a little bit of a rabbit hole. To do office procedures, you've got to fight battles, authorization battles, logistics battles.

[Ashley Agan MD]
For your practice as far as having people to fight the insurance battles or justify all these things, approximately, how many people do you need per office or per patient group, or per doctor? If I was thinking, "Oh, I'm going to start an office-based practice," do I need to have at least one person that's doing that full time? How much work is that? Is that enough work to keep one person busy all the time?

[Madan Kandula MD]
Yes, unfortunately, probably so. Depends on your volume and it depends on your commitment but if, say you've got that a smaller practice or solo practice, or even a small group practice, I don't know that it's a full-time job out of the gate if you don't have the volume there but it's a job. Whoever's doing the authorizations for your surgeries and CTs currently, this is a teachable skill set and it's a learnable skill set by getting the reps, and the reps are just, part of it is just understanding what the insurance criteria are for each specific insurance carrier as it relates to each specific procedure that you're doing.

Understanding that and then testing it out and seeing how things go and then sometimes you'll get things authorized and then they still won't pay on the back end, which is insane to me but that does happen. You need somebody who's standing and doing that kind of thing. If you're just starting out, whoever's doing that work can do this as a one-off thing but once you get going with this, it's something that's, I'd say for most folks who do a lot of in-office work that I know of tend to be solo docs or one or two people practices that just do a lot of in-office work. I think for those types of practices that are doing high volumes of in-office work, they typically have an individual who pretty much is solely fighting these battles. That takes a while before you have that need, but you definitely have the need to some extent right out of the gate.

[Ashley Agan MD]
For patients who cannot get insurance approval, let's say, you've done everything, jumped through all the hoops, and it's just like, "No, this is just not covered." Do you have cash basis where you can offer patients a route to get things done if their insurance company is being stubborn and not willing to work with you?

[Madan Kandula MD]
Yes. There is, We take the authorization battles on ourselves and sometimes we lose. For a patient that we feel medically that, let's just use balloon sinuplasty as a specific example, we feel like that would be beneficial, but the insurance carrier is denying it. Then we have the conversation with the patient as to this is the reality and this is the out-of-pocket that this would mean for you. We try to minimize that bite as much as possible. Then a patient can make the choice.

[Gopi Shah MD]
I wanted to ask you, in terms of somebody starting out, how do you figure out cost and equipment? Do you rely on loans? Do you work with industry? How do you get started because you have your microscope and your scopes in your ENT clinic, but then you need special tools and machines and things?

[Madan Kandula MD]
Yes, to some extent. It depends. Fortunately, I'm minimalist in my needs as well, both in the OR and the office. I try to keep it as simple as possible, which it's good for my sanity, but it's also good from a cost standpoint but with anything, healthcare's expensive. Surgery is expensive. Office-based surgery can get expensive to some extent, but industry will work with you. You could work with industry to soften the blow of getting things started. They've got an obviously vested interest in seeing that you're successful in this endeavor. Industry can do that. You can get loans.

In our early phases at ADVENT and when we started doing in-office procedures, it was just paying for it with bootstrapping, is the way that in other industries they call it. We're just paying for these expenses through taking care of the other patients that we have. In the grand scheme of things, you do need to make sure that the economics make sense for you to even go down this road, but if they do, the numbers don't have to be extraordinary to be sufficient. You need to understand it. I don't know what that means.

At this point, if somebody's starting out and then they look at the numbers, look at what is your average reimbursement for the typical case that you might be doing in the office. Look at your startup costs, think about that, be realistic about that. Understand there's a ramp phase. Understand that all of those things happen. Understand that you, the person that you look at in the mirror is the most likely person to sabotage the whole thing. Meaning when you're stuck in that first case, second case only seeing the pain and feeling the pain and only seeing the expense and not seeing the reward for this. Again, it's the person that looks back at you in the mirror is going to say, "Why are you doing this? Just go to the operating room, your life will be a whole lot easier." I guarantee you more people have been stopped in their tracks from doing in-office procedures by the person who looks back in the mirror than anybody else. It's not like, "Who's going to keep you away from doing this?" It's you more than anybody else. It's not the economics. When you look at it, industry really would love to help you. Again, they've got a vested interest in seeing you successful.

Optimizing In-Office Procedure Efficiency with a Team-Based Approach

Utilizing a team-based approach to care allows each member of the team to take a targeted approach to patient care. At ADVENT, Dr. Kandula has specially trained nurse practitioners and physician assistants to act as “medical ENTs” who can do the initial evaluation of a patient and allow the surgeons to focus on creating treatment plans and doing in-office procedures. This allows each member of the team to focus on what they do best and creates a more streamlined process for the patient.

[Madan Kandula MD]
Back to the question of, what does it look like? I think one of the big differentiators at ADVENT is we have a true team-based approach, meaning we have basically about four times as many physician assistants and nurse practitioners as we do surgeons. What that means for us is that a patient coming in our door is going to see, what we call our nurse practitioners and physician assistants, “medical ENTs.” They don't do surgery. They're really doing the triage, intake, history, physical, that part of things. The good news with that is that you've got a provider who's providing care at the top of their game, and they can be present with their full attention on the patient. A new patient is going to see one of our medical ENTs, and they're going to go through our evaluation, which is starting with the story, starting with the history, going to physical examination. Basically, a very targeted approach and trying to understand what's going on.

Actually, try to approach this with a “most things are simple and typical and some things are rare.” When you hear hoofbeats, think horses, not zebras. That kind of thing. Meaning you're just listening to the patient, but going down the road of, if somebody comes in with snoring or is fatigued, and we look and their exam matches up with that, yes, we'd be getting them set up for home sleep study. Yes, that's true. If somebody comes in with nasal complaints and/or combined complaints, we're going to look to see what's going on, but likely, we're going to be getting imaging to see what's going on behind the scenes.

Which gets back to my earlier point, which is kind of a controversial point that we kind of glossed over, which is: a healthy nose is not just the nose itself, it's the nose and the sinuses. Those are interrelated units. If you separate them out, you're missing half of the situation there, and it doesn't make any sense. One of the things we have at ADVENT, at all of our locations, is we have in-office CT imaging. That's crucial. Without that information, would you treat somebody looking to see what the condition is? If you see somebody's nose and you hear only nasal complaints and you haven't looked in the sinuses, I wouldn't want that. If somebody's taking me to surgery to take care of my septum and they haven't evaluated my sinuses. No, thank you. I really want to make sure that we understand what's going on holistically before you're going to go and intervene with me.

Even that, it seems controversial. I don't know how it got controversial. I go to my dentist twice a year and get X-rays once a year, and they would never think to intervene without information. Yet, we as a specialty do that every day. Then you say, well, why is that? The reality is because point of care CT imaging has been around for 15 years, but it's poorly adopted. Not because the medicines in question, it's because the economics around that don't make sense if you're in a hospital system.

I'm going on all sorts of tangents. I'm trying to step on all the sensitive delicate areas and landmines that exist in our specialty because nobody seems to do it. Anyway, long story short, back to your question. I should stick with the actual question, which is the initial treatment or the initial evaluation is with our medical ENTs. Then once we gather that information, then patients are sitting down with one of our surgeons to go through and figure out a treatment plan that encompasses the nose and the throat and going from there. We can get into further details on that, but I'm trying to be a good boy and stay on point but I'm being a very bad guest, which I apologize for.

[Ashley Agan MD]
No, this is great. We like to go off. We just let the conversation go where it goes and we see what happens.

[Gopi Shah MD]
Is pretty much any patient with sleep complaints or nasal obstruction complaints, or sinus complaints getting nasal endoscopy, a nasopharyngolaryngoscopy, a flex scope? How is that in the initial workup? Is that done with the medical ENT, the PA, or NP, or is it, "We want you to see a surgeon now," or how do y'all do it?

[Madan Kandula MD]
It depends on the history and the headlight exam, but most of those new patients are getting endoscopy because they're coming with airway complaints, and we're looking at their airway. That is done by the medical ENTs typically.

[Gopi Shah MD]
Is it most of the time because of the breathing triangle, you're getting the nose, the pharynx, and the larynx on your exam, or is it just the nasopharynx usually?

[Madan Kandula MD]
It depends on the situation, but most of our patients have that combined issue of snoring. Some degree of question about their oropharyngeal airway. Typically, if we're going to scope somebody, it's looking at the nose, the nasopharynx, the oropharynx, and hypopharynx. They're doing an examination, and I think even at their end, I'd say, how did I get good with flexible laryngoscopy? By doing a lot of those when you're a PGY2. Same thing. Our medical ENTs see these sorts of issues all the time, and they get a lot of reps doing these things, and they're pretty darn good. It's comforting to have well-trained, qualified teammates. Basically, they can do what they do well, and it allows us to step away from that, meaning we can focus on the things that only we could do. That's really unusual. You think about our specialty. We waste and squander our highest level talent doing things that others can and should do, specifically clerical work, which is ridiculous.

Even on to history taking, there's definitely an art to history taking, but really at the end of the day when I'm trying to make clinical decisions, I want the information. I want it accurate. I want to know what's going on. I want the tests that are appropriate, and I want to evaluate that information, synthesize it, come up with a game plan, sit down with the patient, get them educated, and go from there. I'd rather spend my time analyzing, synthesizing, educating, and doing, than gathering and secretarial clerical work, which is probably 50% of what most ENTs do on a day-to-day basis. That's just me.

[Ashley Agan MD]
It makes a lot of sense. Do you train your PAs and NPs so that everybody's, like it's a uniform exam, and this sort of information that you're looking at is consistent, the same?

[Madan Kandula MD]
Yes. There's a training process. Most of our medical ENTs came to us without any ENT background, which is fine, so we can provide them with “this is our construct, this is our process, these are the things you need to be looking for.” There's definitely a certain number of reps on various things that they need to be able to complete. We're formalizing right now, but there's a bit of an oral exam with not just me as the proctor, but it's just making sure that they're really comfortable and confident in their skill set.

I think another differentiating factor about how we do things at ADVENT is there's one playbook, and we're all operating off of that playbook. It starts with the fundamental of the breathing triangle. Literally, it starts with that fundamental of: nose and throat issues are interrelated. Nose and sinus issues are interrelated. We need to be able to see and understand what's going on before we do something. There's a process in order to do that.

The tools and technologies that we have in 2022, a home sleep study, that didn't exist when I was in residency. That breaks down the barrier for us being able to access that information and really makes it questionable, why do you need somebody other than us to offer that to patients? The reality is you don't.

Now, there are some people who need in-lab studies. Those tend to be zebras, though, honestly. Most people who are coming in with more run-of-the-mill snoring, the typical complaints we see, home sleep studies are absolutely fine. The technology is basically in our phones and on our watches and on our rings and things. We have technology that tells us very discreetly what's happening to us on a nightly basis. It's a bit mind-boggling why we have to go 40 years back in time to think about a sleep lab to get information documented that we can figure it out a different way.

[Gopi Shah MD]
Are you reading the home sleep studies as well, or do you work with a pulmonologist to help interpret the sleep studies?

[Madan Kandula MD]
Both. We do have some sleep med colleagues that will work with us. It depends. We've evolved over time, so it's entirely different when you have one practice versus when you have multiple locations and things like that. We're evolving in real-time. We're right in the crux of basically outsourcing those reads. We do do some of those still internally, but it's an evolution. The technology is pretty darn good. Meaning that the computer-generated reads are not 100% accurate, but they're pretty darn good these days. Most of the time when somebody's overreading a sleep study, it's just confirming that there wasn't some weirdness that happened between the data and the report.

Basically, conceptually, on that topic, as much as we can keep in our own control. Not that I'm a control freak, but more just because makes it easier. Once we start having to depend on somebody, what I've found in my career is that they're undependable. I'd rather have the ball. Again, I'm thinking about this in the context of our specialty. We tend to be good boys and girls and sit on the side and wait for somebody to hand us the ball. The problem is by the time the ball is handed to us, it probably has been fumbled 12 times by people who shouldn't have had that ball to begin with. I'd rather have the ball.

Again, I'd rather us as specialists, as ENT specialists grab this ball, meaning the nose and throat. This is our territory. It is ours to own. It doesn't mean we have to. I think the reason we don't take it and make it ours is I think it's like, “It sounds like a lot of medicine. It sounds like a lot of like comp. It's a lot of logistical hassle, and I just want to operate.” You know what I'm saying?

I get it. I guess with how we've done things or been able to construct things, that medicine hassle work that you don't really want to be interested in, we've trained folks who can do that, and it's a teachable thing. Basically, if you can create a system where the things that need to be done that you don't personally want to, you'd rather be doing other things, make sure that that's getting done well, and that's the magic of what we're doing, is you're taking technology that exists today. What that allows us to do is streamline and make it really efficient for our patients and really effective for our patients.

[Ashley Agan MD]
Everyone's doing what they want to be doing, which is great. You have people who want to be doing medical otolaryngology and managing things medically are doing that. Then people who want to be doing things procedurally or in the OR are doing that. That probably makes for a lot of happy people.

[Madan Kandula MD]
We got a happy team. We really do.

[Ashley Agan MD]
Happy people, happy patients.

[Madan Kandula MD]

Podcast Contributors

Dr. Madan Kandula discusses The Future of Otolaryngology is in the Office on the BackTable 72 Podcast

Dr. Madan Kandula

Dr. Madan Kandula is a practicing ENT and the founder and CEO at ADVENT in Milwaukee, WIsconsin.

Dr. Ashley Agan discusses The Future of Otolaryngology is in the Office on the BackTable 72 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses The Future of Otolaryngology is in the Office on the BackTable 72 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2022, October 4). Ep. 72 – The Future of Otolaryngology is in the Office [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



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