BackTable / ENT / Podcast / Transcript #20

Podcast Transcript: Complete Cleft Care & Choosing Your Own Adventure

with Dr. Steven Goudy

We talk with Steven Goudy MD, MBA about his clinical practice and research emphasis on cleft palate care in children at Emory Healthcare, as well as some tips on trying projects/adventures outside of clinical medicine. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Introduction to Cleft Lip and Cleft Palate

(2) Timing of Cleft Repair

(3) Classification of Cleft Lip Types

(4) Hearing Loss with Cleft Lip and Cleft Palate

(5) Comprehensive Cleft Care Teams

(6) Perioperative Care for Cleft Patients

(7) Working in Translational Research

(8) Dr. Goudy’s Leadership and Mentorship Philosophy

(9) Choosing Your Own Adventure in Your Medical Career

(10) Starting a Direct-to-Consumer Medical Device Company

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[Dr. Gopi Shah]
Hello everyone, and welcome. This is the BackTable ENT Podcast. We aim to bring you conversations with the best and brightest minds in the field of otolaryngology with a hope that you can take this information and apply it to your practice. My name is Gopi Shah and I'm a pediatric otolaryngologist here in Dallas at Children's Health.

[Dr. Ashley Agan]
My name is Ashley Agan and I am a general ENT. I practice in an academic setting here at UT Southwestern in Dallas. We've got a great show today with Dr. Steven Goudy. He is a professor in the Department of Otolaryngology, Head and Neck Surgery at Emory University in Atlanta, Georgia where he is the Director for Pediatric Otolaryngology. Dr. Goudy obtained his medical degree from the University of Louisville School of Medicine. He stayed there to complete his residency in Otolaryngology and then went to University of Iowa to complete his fellowship training in Pediatric Otolaryngology.

Cleft and craniofacial disorders are his primary clinical and basic research interests. He does translational research working with a team including orthopedics, internal medicine and biomedical engineering at Emory and genomics at Georgia Institute of Technology. His research team looks at bone and soft tissue biology to develop regenerative therapies for children. The ultimate goal of his research team is to provide off-the-shelf solutions to reduce morbidity in children undergoing craniofacial surgery.

He also obtained a Master's in Business Administration from Emory and is the CEO and founder of a startup company, Dr. Noze Best which develops novel solutions to alleviate upper respiratory tract infection symptoms in children. He is here today to talk to us about cleft care. Welcome to the show Steve.

[Dr. Steven Goudy]
Thank you. I’m very excited to be here. It's an honor.

[Dr. Gopi Shah]
For our listeners, can you first tell us a little bit about yourself and your practice?

[Dr. Steven Goudy]
Yeah, I'd love to. I'm a pediatric otolaryngologist, or I pick boogers and ear wax out of babies for a living. So, I love that. I also love cleft and craniofacial care. I guess I'm a nerd and the embryology of facial growth and development is fascinating to me. Taking care of those patients is quite special. First, it's a transformative experience for the families to have the surgeries performed, but moreover, I'm also able to follow them until they're 18 or 19 years old and so I really get to know them. It's fun. Kids want to get better, and they don't complain as much.

(1) Introduction to Cleft Lip and Cleft Palate

[Dr. Ashley Agan]
The topic of cleft lip and palate is pretty big. Can you first explain what that is and what it means?

[Dr. Steven Goudy]
The meaning of the word “cleft” is separation. So, a cleft of the lip is a separation of the lip. When your body is forming, your face is growing from the sides towards the middle, and the middle part is growing down. If they don't grow fast enough to touch, or they grow fast enough but then they don't join, you get a separation. We all start out with a cleft lip and a cleft palate. But for whatever reason, genetic or environmental or some combination therein, about a 1 in 1000 live births in the U.S. have a cleft or a separation of the lip or the palate. Cleft lip and cleft palate can be present alone, or as part of a syndrome among a constellation of other findings.

Each one of these situations sets the child on a different surgical trajectory and a different care team trajectory. At the very beginning, it's not about any surgery. It's about feeding and breathing and so on. There are special bottles that families need to use and they work closely with speech and language pathologists. Then, there are teams of folks like the American Cleft Palate Association, which is an organization that's dedicated to the care of patients that have these differences. Seeing a team of folks is best because then the team comes to you. This is preferable to a model where the family goes to multiple appointments on different days, where each care provider is pointing at the other one who's responsible for doing something. Having team-based care is a patient centered approach to care.

[Dr. Gopi Shah]
When do you first see these patients? With prenatal ultrasound, you see these families before the baby is born. How often does that happen? At what point in time do you start seeing babies in the NICU?

[Dr. Steven Goudy]
That's a great question. As you mentioned, we are identifying these differences earlier and earlier. Certainly, a cleft lip that is easier to detect than a cleft palate alone. If you've seen an ultrasound, you know that babies are in a quiet dark environment and then when you put the ultrasound on them and they start wiggling around and moving and it's hard to really identify some of these differences. The face grows and develops very early in life, so around the 10th week, their face is almost fully formed. If you're seeing the 20 week ultrasound, you will be able to identify some of these differences and then you can have conversations with the families and help them understand that this is not a consequence of them having a Diet Coke on Tuesday or eating Taco Bell on Wednesday. There's no attribution of blame. The conversation could help them identify what their child's care path is going to be and demystify it.

We do also get consulted in the NICU for babies whose cleft lip or palate were not identified prenatally. At that point we sit down and have a conversation about what their futures look like.

(2) Timing of Cleft Repair

[Dr. Ashley Agan]
When patients first present to you, you mentioned that the first thing you're worried about is basic needs like feeding and breathing. What happens after that, as far as timing of repair?

[Dr. Steven Goudy]
Babies are obligate nose breathers and so if they do have a cleft in their lip, and it's fairly wide, then that gives them actually more space to breathe through. If there is a cleft in the roof of their mouth, then they can't suck very well. That suck, swallow, breathe rhythm is interrupted and there's a lot of time spent trying to get them to eat before we can really consider the operation. They need to be healthy and growing and nutritionally taken care of.

With feeding, there are specialty bottles. There are Haberman bottles, pigeon bottles, and Dr. Brown's specialty bottles. I don't have any disclosures with respect to bottles, so I'm bottle-agnostic. Dr. Brown's specialty bottle can be found at Target, so a lot of families use that one. Assuming that we are on a good trajectory to eat/grow and they are gaining weight, the old adage for a cleft lip repair (which is typically the first thing that you do) is 10 weeks, 10 pounds and 10 grams in hemoglobin. Again, that's an old adage. I don't think that adage is necessarily scientifically-based, but in my mind, this is the earliest that you could repair.

I think there are some folks who are pushing that envelope and trying to do it earlier and earlier just because they feel that there's still some of the maternal progesterone and other things in the system that allow the body to heal with less scarring. There is also some orthodontic stuff that can be used. Nasoalveolar molding can bring the separation closer together to make the surgery easier. This requires weekly appointments where they're building a retainer that stretches out the nose and moves the two alveolar ridges (bony line) closer together. You go from trying to close a pretty wide cleft, to closing a very narrow cleft, which obviously is easier to do.

In general, we're going to fix the lip. If it's unilateral, I operate at three to four months of age. If it's bilateral, I wait until they're five to six months of age. We already said that babies are obligate nasal breathers. If you do a bilateral cleft lip repair, and all of a sudden squash it all up and then sew it together, they can have a hard time breathing. We don't want them stranded in the hospital for a long time figuring out how to breathe and letting the swelling go down.

For the cleft palate repair, I generally operate at about a year of age. This could vary depending on their growth and development: Do they have underlying heart problems or other things that take precedence over palate repair?

(3) Classification of Cleft Lip Types

[Dr. Gopi Shah]
Since we're on the topic of cleft lip, can you go into the difference between complete and incomplete, and how surgery or expectations are different with those nuances?

[Dr. Steven Goudy]
Incomplete means that the separation doesn't go from the top to the bottom of the nostril through the lip, so there is some attachment that is remaining. That attachment has been referred to eponymously as Simonart's band.

Then, you can have lots of different variants of incomplete separation. It can be very subtle, called a microform, meaning very small cleft and so there may just be a tiny notch or indentation in the lip. It can be super wide or it can be anywhere in between. You can have a bilateral cleft lip, meaning both sides, where one is complete and the other one is incomplete. The other interesting part is that in the complete bilateral cleft lip, this central part called the premaxilla can stick way out and so that makes it really hard to fix it. Again, that's the embryologic part from the nasal process, and it has the central and lateral incisors. You sometimes have to kind of push that back and pull it together. You can do a lip adhesion, where you sew the tissue together to kind of bring it back and then do a revision surgery down the road. The goal in most of these surgeries is to recreate the muscular ring around the mouth, the orbicularis oris.

There are some types of repairs, particularly the bilateral ones, that don't incorporate the muscle all the way around. Personally, I think it's important to reconstitute that just because you can pucker your lips and whistle, if you don't get that muscle together all the way then you can have what's called a whistler deformity. This is when you whistle and there's a little notch in your lip and it looks different. Also, at the time of cleft lip repair, we'll put in ear tubes. These babies are going to need about three sets of ear tubes in their lifetime, if they have a cleft palate, the tensor veli palatini is not attached to the other side. There's a very high incidence of conductive and sensorineural hearing loss in these patients so their hearing needs to be screened very closely.

(4) Hearing Loss with Cleft Lip and Cleft Palate

[Dr. Ashley Agan]
On the topic of eustachian tube dysfunction, do you typically see that improve after surgery and after they grow? Or do some of these patients have lifelong issues with eustachian tube dysfunction?

[Dr. Steven Goudy]
The answer is yes. Actually, I wrote a paper on that 15 years ago and the average number of ear tubes that patients get will be about three sets of ear tubes. About 50% of patients will resolve their eustachian tube dysfunction or fluid behind their ears after their palate repair, but 50% won't. They need to be followed long term by an otolaryngologist who understands tympanic membrane retractions, cholesteatoma, and screening for sensorineural hearing loss. A lot of these children will have syndromes which include heart disease, cleft lip, cleft palate, breathing issues, and tracheostomy tubes. Then, all of a sudden, you're a year or two down the road and you realize that this child has sensorineural hearing loss, needs hearing aids, has compounding speech delay and so on. We as otolaryngologists need to be advocates for these children and get proper hearing tests to identify it by one month, confirm it by three months, and treat it by six months. As an ENT, that is the mandate from our society and if we are not involved in the care of these patients, then this causes a potential delay in care and could affect lots of stuff.

[Dr. Gopi Shah]
That's a great point that you bring up. I feel like for babies who are born prematurely or have an extended NICU stay, we do a pretty good job with the newborn hearing screen and then having them come back within that 6 to 10 month period for a behavioral hearing test for delayed onset hearing loss.

For the otherwise isolated cleft palate baby who is a term baby, if they pass the newborn hearing screen, are you going to do the behavior hearing test before one year? On one hand we're always thinking that speech development will be a reflection of their hearing, but I would imagine that cleft palate affects speech and articulation. How do you know how aggressive to be with the hearing tests?

[Dr. Steven Goudy]
I think that they should be screened every six months until you're pretty confident that they're hearing fine, and generally that's probably going to be two or three years down the road. Just as you said, there are lots of risk factors that these children end up having, and there are lots of reasons why they may not be speaking. The benefit of our partnership with the audiologists and speech pathologists is saying, “Have we ruled this out?” It may require a general anesthetic to do a sedated hearing test to confirm that there's no hearing loss.

I would much rather spend a little time to do that, than have these conversations a year or two down the road and say, “Oh, your child has a moderate hearing loss and now we're putting hearing aids on, and now there's speech delay, and you're already in all these thousands of other therapies.”

[Dr. Ashley Agan]
When they're first presenting, you mentioned the incidence of also having other comorbid issues or having different syndromes. Are you referring all of these patients for genetic testing?

[Dr. Steven Goudy]
I personally am. I think that information is power, but there are some families that don't necessarily want that for themselves because they have concerns about social stigma. I don't want to miss things. Lots and lots of these kids have genetic differences. In particular, if they have more than one physical finding, then there is a need for genetics so you don't miss kidney disease or cardiac disease. I think somebody just needs to see them, particularly if there's any type of family history.

For the families, it helps them understand their risk of having another child with the same difference.

(5) Comprehensive Cleft Care Teams

[Dr. Gopi Shah]
Who are the members of a cleft team?

[Dr. Steven Goudy]
I think it's different across the country. Certainly, you want to have a surgeon and the surgeon can be any number of folks with different backgrounds: otolaryngology, plastic surgery, or oral surgery. Also, you need dentistry and orthodontics. You want to have an audiologist, speech pathologist, geneticist, and somebody that understands social work. You may need a psychologist, particularly for the children who have Apert and Crouzon syndromes. These are rare multifactorial conditions and there are a lot of hurdles that these families have to go through.

There are lots of things that these patients need and team care has reliable and reproducibly good results. Obviously the pandemic has really impacted people's access to care. Folks are actually doing cleft clinics remotely or virtually now. There are some silver linings to the pandemic because it allows the cleft team to get into the homes of families that have low resources and barriers to care.

[Dr. Ashley Agan]
The more the merrier for sure. I always feel better working with people who are experts in their area. You mentioned social work. How do they help patients navigate through all of this?

[Dr. Steven Goudy]
You guys are in Texas. Texas is a very big state and I'm sure that there are lots of medical deserts out there where some of these families are making the decisions: Do I drive four to six hours for a single appointment or a day's worth of appointments, or do I feed my family? Who in my environment can help me with formula to feed my baby to grow him or her big enough to have the surgeries? There are families that don't have those resources and social workers can help plug them into the local folks that have access to that.

Here in Georgia, we have a program called Babies Can't Wait that helps babies who are at risk for hearing loss or experience hearing loss in the first couple years of life. From a lean process standpoint, physicians and surgeons don’t need to do social work. That's not us working at the top of the scope. We are compassionate individuals, but we weren’t trained as social workers and certainly we can't execute on that. So, these families need to be supported in that way through social workers and social services.

[Dr. Gopi Shah]
I feel like I've had lots of different situations where I'm so thankful to have a social worker help me make my patients’ care complete and guide me through these difficult barriers. Like you said Steve, we're not trained to do it. We don't understand the mechanisms that are in place or how to utilize the resources that are there. I think families really appreciate when they have a social worker available to them or other resources.

(6) Perioperative Care for Cleft Patients

[Dr. Gopi Shah]
Can you tell us a little bit about your pre-op counseling for the initial cleft lip or palate? How do you counsel families? What kind of expectations should they have? How long do they usually stay in the hospital? What kinds of post-op complications should they be aware of?

[Dr. Steven Goudy]
The cleft lip repair generally takes about an hour or an hour and a half. Obviously, the width of separation determines how long the surgery is and what the scar will look like. If it's a wide cleft and you're moving a lot of tissue around, there will be more tension that causes more scarring. There is no scarless cleft lip surgery. The goal of the cleft lip surgery is to hide the scars. The philtrum are the two lines that naturally occur under your lips. The goal of the cleft lip surgery is to recreate a scar in a similar line as the philtrum and reshape the nose so that it's not flattened.

Recovery time is a couple weeks. The kids are angry because I put No-No arm restraints on them to keep their arms straight and prevent them from scratching at their face. Certainly, they can take those off when the family is with them. Same thing with the cleft palate, they have to wear the No-Nos as well.

As far as risk related to cleft palate, there's a 10% risk they'll be a hole or fistula. Again, the cleft is a separation, meaning that if you have a cleft palate there's a continuous space between your oral cavity and your nasal cavity. That's why you can't create suction and so you're going to close that off by moving tissues or mucosa from the sides to the middle and sewing it up in a very dirty place that undergoes constant physical trauma. Addressing some of the tension can reduce the incidence of fistula formation. but it still happens and then they have food coming out of their nose and their speech is funny. There's air that continues to come out of their nose and so if a fistula does occur, revision surgery is necessary. The efficacy or success rate of those is only about 50% or 60%. In my research, we're actually trying to develop strategies to reduce fistula formation and make it easier to heal.

(7) Working in Translational Research

[Dr. Ashley Agan]
I think that's a great segue into talking about research. We wanted to ask you about your translational research, how you stepped into that, and how it's part of your career.

[Dr. Steven Goudy]
Apparently, I like doing frustrating things that involve a lot of rejection. Basic and translational research is very interesting. I mean, we're all here talking on a Sunday morning because we want to make things better and we want to change things. Translational research allows my scientific brain to bring the embryology and developmental biology aspects to technical surgeries and try to meet somewhere in the middle. I say, “Okay, why am I getting fistulas? How do I control that better?” If you think about wounding and wound healing, folks are pushing all in on stem cells and growth factors for cutaneous wounds or burn wounds. There are not many people interested in oral cavity wound healing. So, as I've done in my whole life, I surround myself with people that are smarter than me that help answer these questions.

[Dr. Gopi Shah]
That's why I talk with Ashley every Sunday.

[Dr. Steven Goudy]
Exactly. It makes you feel smarter.

I'm working with a bunch of engineers at Georgia Tech and they have lots of cool toys, growth factors, and delivery vehicles. However, they don't really know what the clinical application is and so that's where I wanted to be a basic scientist and look at DNA and mouse models of genetics. Initially, I didn't do very well at that because I was doing surgery all the time. I realized that I needed to pivot. “Pivot” is a word that basically came out of 2020 and 2021, right? I thought: Okay, well I'm not being successful here. I love science. It's relaxing to me and every time I get new data, it's like I'm unwrapping a Christmas present. By leveraging the folks around me, we've identified something that can enhance wound healing in the oral cavity using an already FDA-approved drug to reduce fistula formation in a mouse model.

We are always thinking about the pain points that families have. It’s bone biology, so we are trying to make more bone. We haven't talked about filling the gap in the alveolus or the gumline. Currently, you have to do a hip graft, and the kids are limping around for a week, they have to stay in the hospital overnight, and they may end up getting a hip fracture. That doesn't sound very cool. So, there needs to be a better regenerative strategy for that.

That's part of my lab and then the other part is oral mucosal wound healing. Again, I care about kids because they're fun to take care of, but there is a bigger market size actually for the older people that have gunshot wounds or cancer surgeries. As a society, we need to push hard to have better off-the-shelf strategies rather than doing a free flap, which is taking a piece of your leg and putting it in your mouth. I mean, if you need it, you need it. But it doesn't sound great if you could avoid it or get something off-the-shelf.

It’s really my curiosity and harnessing those pain points that we see in surgery and saying, "Why are we doing this?" I mean, there has to be something else. If I can have an iPhone that's the size of my palm and solves every problem I never knew I had, why don't we have that same sophistication with different therapies? We haven't moved the needle on any of that in a long time.

[Dr. Gopi Shah]
For somebody who’s starting out, like they're finishing their residency or they’re within the first two to five years of their career, how would they actually get into translational research? How do you develop a research team?

[Dr. Steven Goudy]
I think there are a couple components. Number one, you need a little bit of training or exposure. It can be formally or informally, just so you understand what it is that you're doing and why you are doing it. You have to have mentorship. Mentorship is so important and some of my successes and failures have been tied to having good mentorship or not having good mentorship. If you don't have good mentorship and you don't have somebody who's going to fight for you and knock down the walls that you're approaching, then you're not going to make it. There are lots of ways that you can find your path, but if you really want to go into a field where you're going to spend months and months writing a grant that only has a 5-10% chance of getting funded, you have to love rejection and have good mentorship. This means having somebody patting you on the back and pushing you up the hill over and over. It's almost like Don Quixote attacking windmills. Having said that, I wrote 18 R01 grants just to get one.

Not to be super wonky, but if you do a Birkman personality assessment, you can learn more about yourself. I finally realized that scientific curiosity actually is relaxing to me and that's why I gravitated to it. If you do a self assessment, whatever that is, and you find out that you're set on doing something that stresses you out, you need to think about that.

(8) Dr. Goudy’s Leadership and Mentorship Philosophy

[Dr. Ashley Agan]
That's great advice. I love that you mentioned mentorship because Gopi and I talk about that a lot. When you start to talk to people who have been really successful, that recurring theme always comes up. What's your advice for people who are trying to find a mentor? Are you just really good at networking, or did you just happen to know these people already?

[Dr. Steven Goudy]
That's a great question, and the answer is multifactorial. Again, it's all about knowing yourself. If you're an introvert, you have to say, “Okay, I'm an introvert, this is super uncomfortable but I'm not going to succeed if I'm not surrounded by good people.” You have to surround yourself with good people. If you're just starting out, before you take whatever your first job is, you have to find out who can help you there. If you want to be the first otolaryngologist to ride in a NASA spacecraft, you need to find somebody that actually knows somebody, because otherwise, if you go to the department and then you tell them your goal, they're going to say, “That sounds kind of crazy and here's a whole bunch of patients for you to go see.”

From the outset, you have to be very introspective. Say, “Who am I? Can I do this? What are the things I need?” Ultimately from your residency program, fellowship program, or wherever you are, you should have that conversation with your mentors. Assuming that they know you and you've been nice to them, they want to see you succeed.

If you've been somebody who is climbing on the shoulders of other people but also stepping on their head on the way up, that's not the way to do it. If they're people who are putting you on their shoulders, they're going to help you. They want you to succeed because that's their legacy. Again, the rejection part is real and not everybody's going to want to help you. It all comes back to mentorship and saying, “Okay, I'm considering this job at XYZ place and this is what I'm passionate about. I will be asking them: Who are my mentors? How are you going to support me? How is this going to work? What's the balance of time, etcetera?” It is important to have this all understood on the front end, because otherwise if you get there and they're planning for A and you're planning for B, somebody's going to see their way out.

[Dr. Gopi Shah]
As the Chief of Pediatric ENT at Emory, how do you mentor your faculty? Is it different for every faculty member?

[Dr. Steven Goudy]
I have made lots of changes to my approach. Business school was super helpful in that because businesses actually understand that mentorship is building the pipeline. In medicine, we're not ever taught about building the pipeline.

When I started in my residency before the dawn of time, there was one attending that we worked with so you could measure your success and failure by the “Attaboy'' to “Gosh darn it” ratio. If you got more “Gosh darn it’s” than “Attaboy's,” then that was a bad day and you just had to figure out how to do it differently.

I've been the division director for six years. At first, I was trying to manage people and have them execute on the things I thought would make them happy, but that doesn't make people happy. It ultimately makes them feel like they are being micromanaged and people hate that a lot. I can tell you from personal experience.

Again, I have done some self-reflection and pivoted away from that. One of the big terms that comes up over and over in business and leadership is psychological safety. You need to create psychological safety for the folks in your environment so they give you feedback when you are being pushy or micromanaging. Sometimes, I will just let people do their own thing. I say to them, "Look, I brought you here to take very good care of patients and if you're doing that, that's all I need you to do." If they want to get promoted, that's very different. I’ll say, “Here are the things that you can do.” In some ways, it's a “choose your own adventure” kind of story.

I like giving people things to do. I like to delegate and grow people's careers, but then there are people that say “Hey look dude, I'm full. Good, no mas.” I want them to have psychological safety and engage in a conversation with me.

Even onboarding has changed. There are so many things that people want to talk to you about because it's super stressful to start their first job and they have their first complication. That can be very injurious to them and if I haven't prepared them for that, then that's hard. It's hard for them. It's hard for me. It hurts everybody.

Our division has six female surgeons and two male surgeons. The lives that my six female surgeon partners walk is very different, so I try to hook them up with other mentors that have walked that same space. Overall, my leadership has evolved overtime.

[Dr. Ashley Agan]
When I think about really highly functioning successful organizations, I feel like it's an orchestra where everyone is living their best life and really living out what they're passionate about, which is different for everyone. So, you have some people over here who just read the white journal in their free time.

I love that approach of creating your own adventure. It can look different for everybody. We're not trying to make all these clones.

[Dr. Steven Goudy]
Yeah, we don't need everybody in the department to be the chairman or chairwoman. Right?

[Dr. Ashley Agan]
Exactly.

(9) Choosing Your Own Adventure in Your Medical Career

[Dr. Gopi Shah]
In medicine, there are certain boxes that you have to check to get into medical school, residency, and then fellowship. So, the “choose your own adventure” mindset can come a little late for some of us in medicine. I feel like it's important to encourage our residents and our medical students to adopt this mindset earlier. It’s difficult because they are going through a match process and they cannot choose as much. There are so many things for them to learn in terms of self awareness, self empowerment, pivoting, and understanding how to say yes/no to things they like/dislike. This growth is a process that continues to evolve, and it's important for us to encourage this in our trainees and our colleagues.

[Dr. Steven Goudy]
Absolutely. When I hire folks, I'm hiring them for a pretty specific thing. I have that conversation on the front end to manage their expectations. Sometimes I say, “We already have two people to do XYZ surgery, and we don't need a third person. If you're coming here for that reason, that's not what we need.” I make sure their basic fundamental expectations are being addressed, and then from there it's what growth do they want and how they want to balance their lives. I think it’s important to leverage the university or the practice or wherever you're in to get the most out of that. As surgeons, a lot of us put our heads down and just grind, or at least that's the way it used to be. I don't know if that's happening as much anymore, but we need to pick our heads up and say, “Okay, what are people trying to help me do?”

For example, Emory has a lot of dedicated time for the younger folks to have career development. This includes training for how to be a good teacher and how to deal with negative patient feedback. Sometimes, our doctors are used to getting hundreds on all their tests and then somebody gives you what feels like an F. It's hard. Despite the fact that there's a hundred people that walked out of the office that day that loved you, there is one person that doesn't like you.

[Dr. Ashley Agan]
It's true. Those words hurt.

(10) Starting a Direct-to-Consumer Medical Device Company

[Dr. Ashley Agan]
Well, can't let you leave us today without talking about Dr. Noze Best, your startup device company. Can you tell us a little bit about how you started that, what that is, and what it does?

[Dr. Steven Goudy]
This dovetails into what we were discussing earlier. So, babies are obligate nose breathers. When they get a bad cold, they can't breathe, they can't eat, they cry all night, and you don't sleep. It's a super tense, uncomfortable moment. My kids have been in daycare, even as an ENT, I’m frustrated. The blue bulb doesn’t work. It occupies your whole hand so you're trying to get in there while they're clawing at you. Then, there’s the mouth suction device where you put one end in your mouth and you put one end in their nose. I've never used that but that's not hygienic and again, you're still having to fight and chase your kid around because you physically can't hold their face, arms, and legs. My wife had told me, “Hey, you need to come up with something better.”

Again, curiosity, finding pain points, and listening to families guided me. I have a distinct memory of going into a family’s hospital room five years ago. The baby had Down syndrome. We all know that those babies have smaller noses, so when they get a cold, they can't breathe. The mom was stuck in the hospital because she just needed this wall suction. She had bought a very expensive nasal suction device that's basically a small vacuum cleaner, and she didn't have a lot of disposable income. She felt paralyzed by her current situation. So, we created a nasal suction device that fits on your index and your middle finger so that you can use your thumb and your pinky finger to hold the baby’s head. With your other arm, you can actually hold the baby’s arms and be very efficient. This pump provides hospital grade suction.It's rechargeable and portable. If I'm willing to pay $1000 for this little electronic thing, I want something that's going to be efficient and let my baby breathe so I can sleep. A good night's sleep is worth a lot.

Dr. Noze Best is going to be a company that focuses on these pain points. I read an article a couple weeks ago that called it “silent suffering.” Why are we suffering in silence? Why are we using these unsophisticated things to take care of the thing that we are willing to die for? We're willing to pay anything and do anything, but we're kind of bringing a knife to a gunfight.

Our company is centered around health and wellness products for babies and young toddlers. Nobody told us about a lot of things that are part of being a parent. Sometimes, we’re so sleep-deprived that we don't even realize that the things we’re using are stupid and a waste of money. The goal is to educate parents. If they Google “cold,” they’re going to get a bunch of information, but who should be telling them about management of colds? It should be us, otolaryngologists. Our hashtag is #SnotAProblem. We should educate families on what evidence-based practice looks like.

[Dr. Gopi Shah]
Are families able to purchase it yet? Where can they find it?

[Dr. Steven Goudy]
We launched about six weeks ago. We are available direct-to-consumer on our website, DrNozeBest.com. We're also available on Amazon. So far, we've had great feedback about the device’s effectiveness, and parents don’t have to pin their kids down to use the device. We want to restore that mom or dad and baby relationship because that's next level nasal suctioning. We’re working on product number two that will come out in late 2021 or early 2022.

[Dr. Ashley Agan]
Yeah. I love that. I mean, we're developing commercial space flight so I think that we should be able ake care of a snotty nose with a better system than the current one.

[Dr. Steven Goudy]
Exactly. Well, I think I would also point out that the other devices cause the baby to inhale viral particles into their distal alveoli, that does not make a lot of sense to me.

[Dr. Gopi Shah]
That’s true. Well, congratulations Steve. That's so exciting. I'm super excited to check it out for myself as well.

[Dr. Ashley Agan]
Any other final pearls or thoughts that you want to leave about cleft care, research, leadership, startups, or life?

[Dr. Steven Goudy]
I think being curious and finding good mentorship are the most important things. Try to determine where you are. What are your gaps? Do you want to close them? Honestly, when I started doing that in business school, I looked at my personality, normative behaviors, and stress responses. I became a better husband and a better dad. If I could go back and do it again I would've started down that self-reflection journey 20 years ago rather than 5 years ago.

[Dr. Gopi Shah]
Awesome. Well, thank you so much Steve. It was really nice to connect with you today. We appreciate your time.

Podcast Contributors

Dr. Steven Goudy

Dr. Steven Goudy is the Director of Pediatric Otolaryngology and Professor at Emory University. He is also the CEO and Founder Dr. Nozebest.

Dr. Gopi Shah

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

Dr. Ashley Agan

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

Cite This Podcast

BackTable, LLC (Producer). (2021, April 13). Ep. 20 – Complete Cleft Care & Choosing Your Own Adventure [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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.