BackTable / ENT / Podcast / Transcript #72

Podcast Transcript: The Future of Otolaryngology is in the Office

with Dr. Madan Kandula

In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Mandan Kandula, founder of ADVENT, an ENT private medical practice, about embracing in-office procedures and building an efficient ENT private practice. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Defining The Breathing Triangle

(2) Approaching Team-Based Care in Otolaryngology

(3) Management of Obstructive Sleep Apnea

(4) Procedural versus Non-Procedural Options Through the Nose

(5) Special Considerations for Allergic Patients

(6) Types of In-Office Procedures

(7) The Hurdles of Providing In-Office Procedures

(8) Working with Pediatric Populations

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Ep 72 The Future of Otolaryngology is in the Office with Dr. Madan Kandula
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[Ashley Agan MD]
Hi, everybody. My name is Ashley Agan. I'm a general ENT and I practice in Dallas, Texas. Joining me today, my lovely co-host, Dr. Gopi Shah.

[Gopi Shah MD]
Hi, everybody. My name is Gopi Shah, and I'm a pediatric ENT. We have a really great show for you guys today. Dr. Madan Kandula is an otolaryngologist sinus and sleep surgeon. In 2004, Dr. Kandula founded ADVENT, which focuses on the breathing triangle. Since its inception, ADVENT has grown from a solo practice with one office in Milwaukee to a thriving organization with over 240 employees operating 13 clinics in four states. He's here today to talk to us about the profound impact of the nose on the body as a whole and why the future of otolaryngology is in the office. Welcome to the show, Dr. Kandula. How are you?

[Madan Kandula MD]
I'm doing great. Thank you. Thanks for having me.

[Ashley Agan MD]
Thanks for taking the time to be here with us today. We like to kick off the show with just hearing a little bit about you. Who are you? Where are you from? What's your practice like? Tell us more about you.

[Madan Kandula MD]
Absolutely. I was born and raised in Dayton, Ohio to a family of physicians. My parents came over from India. I got two older sisters there. My parents are docs. My sisters are docs. My sisters are both married, and their husbands are physicians. Lots of physician influence in my background. I left Ohio and went to Duke for undergrad. I went to med school out in Philadelphia, which actually my kids think it's my one claim to fame, is that I was in the same med school class as Dr. Pimple Popper. That, apparently, for my kids is like I don't need to do anything else because I'm that cool now.

Regardless, I left Dr. Pimple Popper, and I went off to ENT residency out in Oklahoma. That's actually where I met my wife. My wife's an audiologist. We came up to Milwaukee in 2003 and funded our practice in 2004. The practice is called ADVENT, as you guys said. That's the shorthand version of Advanced Ear, Nose, and Throat specialist. That's where the ADVENT comes from. Really, to fast forward through time, 2004 until 2014, solo doc, one office doing what solo docs do and adopting technology as it came out. In-office CT imaging, balloon sinuplasty, coblation, so forth, and so on. I have always liked to push the envelope as much as possible.

Somewhere in the 2014 era, I started getting frustrated on behalf of my patients who were suffering with conditions that were imminently in our control. Especially with office-based treatments, specifically folks who have sleep apnea, they can't breathe through the nose, they get sinus infections. The simple tools that we now have available that we didn't have when I was a resident were game-changing, and yet our specialty as a whole has not adopted those things. From 2014 until now, it's really been trying to connect the dots between the tools and technology we have as a specialty and all of the patients in the country who could benefit, and we are just getting started.

Our growth is really just a reflection of the fact that there are so many people out there who are needlessly suffering from conditions that we can impact, and our specialty, ENT, as much as I love it, us standing in the corner, looking at ourselves, and not stepping forward to help our patients, is not doing anybody a service. That's what I've chosen to take on as my life's work. I'm stepping us out of that corner and I'm stepping towards patients who could benefit from us, and it's a great thing.

[Gopi Shah MD]
I love that. Can you tell us more about the breathing triangle? Is that the foundation, or the base of this?

(1) Defining The Breathing Triangle

[Madan Kandula MD]
Well, the breathing triangle is a term that I had to coin for the nose and throat. I think most people know what an ENT is and you hear that terminology and obviously, we're in the field, so we know, even a layperson knows that. But when you break out the nose and throat as an isolated unit, nobody knows what you're talking about. The breathing triangle is the nose and throat. What does that mean? You have three passages that you can breathe through, and if those are working properly, your life is going to be as good as it can be; and if any of those areas are working improperly, your life will be impacted. That's the breathing triangle.

It’s a very, very simple concept. As a specific example, folks who have obstructive sleep apnea, they have a breathing triangle issue, meaning they have a throat issue 100% of the time. I'd venture to say probably 99.9% of the time, they never have an ENT that's in their care. That's not helping them. It doesn't help folks who have sleep apnea to have pulmonologists and neurologists and psychologists trying to manage the throat issue.

Basically, the breathing triangle is a concept that I felt like I needed to create as a category because nothing really existed, and those areas are absolutely intertwined. If somebody has sleep apnea, like I said, they've got a throat issue 100% of the time. They almost always have nose and sinus issues that are interrelated. They may not know about it. That may be something they've had their whole life. How are they supposed to know that it's not normal to have to breathe through your mouth when you're sleeping at night? That's not normal. Anyway, we do a lot of education for our patients in the community, just trying to let people know that you don't have to live a compromised life.

[Gopi Shah MD]
Even in residency education training, we don't connect the dots well as concepts, much less for ourselves sometimes, and everything's split apart. You have the otolaryngologist that just does sleep surgery. You have the rhinologists and sinus person. You're right, it is something that's all intertwined and connected, but if we don't think of it that way, it's easy just to focus on that one area and then this, how it all functions together.

[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.

It's just putting those simple things together, and even conceptually, I guess, asking you guys a question. When I went through residency, nobody ever told me the definition of a healthy nose. In your opinion, what does that look like? What's a healthy nose? What does that mean?

[Gopi Shah MD]
Is that with, or without boogers?

[Madan Kandula MD]
I've been saving this question, but what's the definition? What's a healthy nose?

[Ashley Agan MD]
What does it look like, or what is it?

[Madan Kandula MD]
Like hey, I'm in fifth grade, I'm just wondering. Can you tell me what a healthy nose looks like? I hear you guys are nose specialists.

[Gopi Shah MD]
Can you breathe with your mouth open or closed?

[Ashley Agan MD]
I don't know. I would say probably something about being able to breathe comfortably without obstruction and with just the right amount of mucus. You don't want to be too dry, but you don't want to have too much running out of your face or down your throat. What else? You want to be able to smell. Your nose is good for being able to smell, heating and humidifying the air that you breathe, filtering the air that you breathe. What do you think? I don't know.

[Madan Kandula MD]
I never have. We never talked about that topic, and I never had a single moment of, what does that look like, or what does a healthy airway look like? My definition as a specific example for a healthy nose is: is the nose and sinus anatomy patent and lining relatively calm? That's it. If somebody has a nose issue, then conceptually, either there's an anatomy issue or there's a lining issue, or there's likely both. Most people have both of those issues who're suffering. 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]
I think you make so many good points. I definitely have a lot of patients who have fragmented care because they see their pulmonologist, or different doctors managing their sleep apnea, and then they have an allergist, and then, oh, they're coming to see me for something else. It does feel like there could be a better way. It certainly, by focusing on just the breathing issue and everything around it, certainly, I'm sure the patients appreciate that. Because, from that standpoint, it's like you have somebody that can offer you everything to address that.

I would love to get into what it looks like when these possible sleep apnea patients come in because I agree with you. I've talked about snoring to patients, and sometimes when I say, "I think we should get a sleep study," or, "Have you had a sleep study?" and there's that look like, "Oh, don't even bother. I don't want to wear that thing." or "I probably have it, but I know I'm not going to want a CPAP, so let's not even go down that road."

(2) Approaching Team-Based Care in Otolaryngology

[Madan Kandula MD]
Yes, absolutely. That's very, very common. You guys know that. Personally, I don't have sleep apnea, but if I did, that wouldn't necessarily be my first option. If somebody said, "This is really something you need to do, and we can make you successful with it," fine, but it's not particularly a sexy or appealing treatment option. That's sort of the elephant in the room as far as CPAP goes. Everybody knows that. You don't care if you're a doctor or a surgeon or you're just a plumber or whatever. It's just a bit weird. It's very much more accepted and adopted these days, but it is still a bit weird.

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]
Absolutely.

(3) Management of Obstructive Sleep Apnea

[Ashley Agan MD]
Going back to our snoring patient that comes in, they got their sleep study and it shows maybe they have moderate or moderate-severe OSA. What happens next?

[Madan Kandula MD]
How do you say it? Yes, we're going to gather that information, we're going to process that information, we'll typically review. There's typically parallel paths between the nose and the throat. The throat path is HST, review HST. What is it telling us? Is that accurate as it relates to what we're seeing when we look at you? Then describing treatment options for that specifically.

Now, we're a bit downstream at this point because we're talking about the throat. Really, just very simply, if somebody has, say, it doesn't really matter. Mild, moderate, severe, you take your pick. The option or the algorithm is pretty straightforward. Downstream, the algorithm is we can use a CPAP appliance, we can use an oral appliance, or we can think towards procedures. Those are the three pathways that exist. None of those treatment options are going to work optimally if the nose and sinuses aren't working properly. We're not jumping to that unless it makes sense to jump to that.

It sounds so simple. It really does sound simple. Meaning, geez, the start of the airways is the nose, why would you bypass the nose to focus on the throat? The only reason that that's the standard of care is that people who can't handle the nose are the ones who are treating most of these patients: pulmonologists, neurologists, psychologists. They don't know what to do with the nose, and so they just focus on the throat. Regardless, I guess back to the point, that from a throat standpoint, those are the options, but we'll educate on what does this mean? What's the impact of this condition? Here are the options. Just focusing on that part of the equation.

There's a huge difference between a CPAP or an APAP fit with a full face mask versus a nasal mask, massive. Within the medical community, there is no dispute that the best route for CPAP is nasal. Nobody will dispute that, yet the most common route for CPAP is a full face mask. Why is that? It doesn't have to do with the medicine, it has to do with the logistics and the convenience. 100% of folks who have sleep apnea have a throat that's too small for the body. That's where that issue's coming from. The majority of those individuals have nose and sinus issues, or anatomy that's also challenged. Nobody's looking at that, nobody's treating that.

If you don't treat that, well, guess we're going to have to put a full face mask on you. Don't be surprised if two-thirds of folks who get set up with a full face mask don't tolerate it. Regardless, it's focusing on, “We got a throat issue. Here are the treatment options.” Always at ADVENT, it's like, let's look at the beginning, and let's see what's happening there.

Very commonly, if somebody's been set up for that pathway to get an HST and review the sleep study, at the initial visit, who evaluated their nasal anatomy and evaluated do they have a deviated septum, do they have turbinate hypertrophy, nasal swell body hypertrophy, valve issue, what do we have there? That's already documented. Like I said before, oftentimes, it's going to be getting them set up for imaging of the sinuses so we can see a full story. We know what's going on in the nose anatomy-wise. Now we can see what's happening in the sinuses. Now let's have a conversation about what we're seeing there.

If we're seeing issues there, we're going to start there. Even if we know that you have sleep apnea, or especially if we know you have sleep apnea. We want you to have the best chance for success, and that's making sure your nose and sinuses, that unit, is working properly. It depends. I'm jumping to that other side of the equation, but that's the pathway that's sort of, those two roads are intertwined, and if you separate them out, then you're just doing what everybody else does in treating these areas, and we don't need to stoop to that level in our specialty.

(4) Procedural versus Non-Procedural Options Through the Nose

[Gopi Shah MD]
Just going back to the nose and the sinus. In terms of breathing treatment through the nose options, other than saline rinses, nasal steroid sprays, what are our options?

[Madan Kandula MD]
You mean non-procedural options for the nose?

[Gopi Shah MD]
Both, both. I would imagine everybody probably gets some non-procedural options first.

[Madan Kandula MD]
Going back to what I was saying before, that simple basic of: you have a nose issue, you have a nose and sinus issue, you've got an anatomy issue or a lining issue. What you're describing is treating the lining. Any medication, whether it's a nasal spray, Flonase, Budesonide, you name it, those are lining treatments. It depends on the patient. Many of our patients have already, they've come to us, they've tried rinses, they've tried Flonase, they've been on antibiotics for sinus conditions. They've been there, done that. At the end of the day, it's up to us to process that, look at them, and say, "Let's come after this, and let's see."

Typically at that new patient visit, it’s evaluating what somebody's done, evaluating what the health of the lining is, and determining, should we try Dymista and whatever the right different angle may be. Let's try that. Let's maximize the lining treatment. Do we need to do allergies testing? If so, let's think about that. Most of the time, the biggest change we can make for our patients is impacting the anatomy. If somebody can be treated with lining treatments, that's fine, but most folks have a combined issue.

Our philosophy is really an anatomy first, office first mindset as it relates to getting that anatomy open. Keep it simple. Let's go for the low-hanging fruit. The lowest-hanging fruit in our specialty is turbinate hypertrophy. Medications can take the edge off of that lining. If we effectively diagnosed, and effectively offered and treated folks with turbinate reductions in office, just because it's so much easier from an access standpoint, we would change the state of health in this country in a profound way.

That one simple thing, and it's something we all learned how to do in our first year of ENT residency, and yet the thing that frustrates me is there are millions of people out there who are suffering needlessly, noses that are blocked up. It's something that takes us five minutes to do and we're unwilling to do as a specialty, not because we don't. I'm sure there are people out there who don't believe it like, "No, that's not true," and I understand that. And then there's the whole empty nose ghosts that haunt our psyches, and I understand that too. At the end of the day, I'd say, I'd rather give somebody patent anatomy versus having them suffer with a challenged anatomy.

[Ashley Agan MD]
On the topic of turbinates, how do you decide if turbinate hypertrophy is the key to unlocking better nasal breathing for the patient? As a follow-up, what is your turbinate reduction method of choice?

[Madan Kandula MD]
Here's what I'd say. I am humble, meager, weak. It's impossible for me to know for sure. Some of these turbinates, is it their septum? Is it their nasal swell body? Is it the valve? Is it that they've got sinus outflow tracks that are tight or that they've got inflammation in the sinuses, or the allergy part of things? There's a lot of things where it's like, "Ah, you know" but it's hard to give you a straight answer without seeing an individual patient.

The assumption for somebody who's coming to us with, "Gosh, I've got congestion. I have a hard time breathing my nose." Maybe it's just happening at night for them. When you lay down and your left side stuffs up. When I lay on my left side and I flip over, and we look in there and things look tight, turbinate reduction is something that's going to come to us. That is the most likely intervention that we're going to think towards for a patient, and that might be a combination. Oftentimes, it is with swell body reduction, many times with balloon sinuplasty if that's indicated, so forth and so on. That is the key to unlocking the nasal airway. It's the simplest thing we can do. It's a very reproducible result.

We have a variety of techniques. It is the reality. Basically, a volumetric reduction by whatever means necessary is effective. Whether that's coblation, whether that's microdebrider. I've reduced turbinates probably every single way that's possible. The only common theme is if you do it effectively, you get good results. Again, the things I'm saying, there's controversy in the nuance. To me, what is an effective turbinate reduction? An effective turbinate reduction is reducing inferior turbinates front to back.

I don't know how. I don't understand the physics of those in our specialty who profess that it's only the anterior head of the inferior turbinate that matters. I took physics, and that doesn't make any sense at all. How is that possible, that that's where it's at? Somebody's going to have to educate me on that one. Again, to me, we, and I'd say it started with me, like to impact turbinates in a meaningful way. We're not shy about it. It's just saying, "This is an issue, let's get it out of the way."

Honestly, if you think about our specialty and my particular practices, we do fewer septoplasty than any practice that sees the number of patients that we see, by probably multiples. What you'll find is, some people do care about the fact that their septums are deviated, but most people just care about the fact that they can't breathe. If you have a crooked septum and you gain space around that, you could do it in an office setting where somebody's back to life immediately versus having to take them to the OR. That's not necessarily your choice to make, but it is your duty to offer that option. Meaning if you can't offer that yourself for whatever reason, you owe it to that patient to make sure they understand that that option exists. Maybe we can't do it here because a hospital doesn't allow us to do in-office procedures. That's a whole separate conversation.

Regardless, I'd say that that option keeps more people out of the operating room than anything else that we do. It's like, on one hand, we're aggressive on how we think about turbinates and how we think about taking care of that issue, but we're much less aggressive. The least likely place for us to do a procedure on a patient is in an operating room. Basically, 95% of our cases, we do in the office. 5% in the OR, which is highly unusual.

(5) Special Considerations for Allergic Patients

[Gopi Shah MD]
Before we go to 95% in the office, because that is super interesting, and I think that's also a big part of this conversation. Just in terms of inferior turbinates, do you think differently for your patients that are really bad allergy patients? Do you ever worry about taking too much, or how often do you have to revise? Those are the kinds of things that tend to always make me, I guess, be a little bit more conservative because I'm like, "They tend to grow back," but how often do you actually see it?

[Madan Kandula MD]
There's what we've been taught, and there's what you see. What I see is that a thorough turbinate reduction, it's hard to describe. "What is he saying when he says thorough?" Not a bashful turbinate reduction. An adequate reduction where there's adequate patency through the nose front to back for everybody who could benefit from that, who's got anatomy that's tight, especially allergy patients. The times where allergy patients fail, this is what I see and this is what I strongly believe is, an allergy patient who is coming to you with nasal obstruction, they've got an anatomy issue, likely. Number one, they've got a lining issue. If they're an allergy patient, they're telling you, or their body's saying, "I've got a lining issue." That's one thing. That lining issue over time is going to create an anatomy issue. If you have inflammation in the lining of the nose, over time, that's going to create turbinate hypertrophy. That's what happens.

Why does that happen? Because the body perceives the world as an enemy and is shutting it off, and is trying to shut it down. If you try to just treat the lining issue when the anatomy is already compromised, you can't adequately treat the lining issue. Even Flonase isn't necessarily going to get where it needs to go. It is making sure that the patient's aware about what's going on, making sure you're aware about what's going on. In that scenario, it would be doing a thorough turbinate reduction, making sure that the patient is aware upfront that we are addressing the anatomy component of this. There is a lining component that is important to treat as well. Whether we're going to treat that with medications or immunotherapy or whatever the case may be, the optimal situation for you is your anatomy’s patent and your lining’s calm. If we get you to that point, the likelihood for having to go back and touch the turbinates is minimal. It's not nothing, but it's as low as we can make it be. That's good enough for me, and it's generally good enough for most patients. If you just tell it like it is to them.

Now on the flip side, say we do a turbinate reduction on somebody who's got massive allergy issues or inflammation issues, just generally. They've got a much higher, and we're not able or they're not willing to treat that lining situation, they have a much higher likelihood of a recurrence of the turbinate hypertrophy. When it is a choice that they're making, they need to understand that that's the choice that they're making. Some people just have inflammation and there's nothing that, you can do everything you want, and we're all helpless sometimes and they're helpless. Those patients, you do a turbinate reduction, they've got massive inflammation, nothing that you're trying is helping the inflammation. They're going to be more likely to have to have that turbinate reduction done again.

People are people, and people absorb things differently. But if you're putting it just out there in front of somebody, I think we fear, I think I was born or bred to fear. Like "God, what if I do something and it doesn't work, and now I'm the worst person in the history of the world and the patient is going to hate me and they're going to tell everybody that I'm the worst person?" It's like, "No, I don't think that's actually a healthy mindset." I think you can control what you can control, and it's your duty to control that. Then there's the stuff that you can't control and you let that go. I've been meaning that, you don’t just go like, "Whatever." But I think you can recognize that and you could say, for that patient, like I just said, if you've got this inflammation issue and say we do a turbinate reduction, you're feeling great, you're breathing through your nose, like, "I'm doing great. This Flonase, I don't like the taste. I don't like the smell, I don't want to use it. Then you say, "Yes, I hear you. When we're looking in there and we see inflammation in the lining over time, that might steal away the gains we just made. I want you to be aware of that," and they say, "Understood. I don't care. I'll be back here in 10 years," or whatever the case may be. That's their choice. I don't know what else we would do about it. Sometimes I feel like we are fearful of having just honest and frank conversations with our patients, and they're dying for that conversation oftentimes. They want that. They can handle the truth if you can just deliver the truth, but we far too often bury the truth. I don't know why we bury it. It doesn't make sense to me, but yeah.

(6) Types of In-Office Procedures

[Ashley Agan MD]
Very well said. Transitioning to talking about office procedures and what can be done in the office, do you have almost like a menu of options that you sit down and talk to patients about and be like, "Look, this is the technology we have. This is what can be done in the office, and then out of all of these things we do, these five things might be something that could help you in particular." How does that look like, and what is on your menu?

[Madan Kandula MD]
Sure, that's a good way to look at it. From an anatomy standpoint in the nose, the components or the areas that we consider: septum, turbinates, swell body. I always felt like turbinates and swell body, they're the same thing, it's just a different location of a turbinate. It's a septal turbinate. Still, I feel like it’s especially still learning about what do you do with that one? Basically, you've got the septum, you've got the turbinate, whether it's inferior or septal turbinate, you've got the valve, for the majority. Some people might have polyps and some people might have adenoid hypertrophy, but if you took the large majority, those are the components. It depends on the patient, it depends on the situation. Out of those components, that our preference as far as intervening is the turbinates first. So inferior and septal, and then it depends. Septum versus valve tend to be backburner kind of things. The septum is very easy conceptually. You see it, you can address it. We tend to do our septums in the OR, which there's a whole conversation around, "Why do you do that?"

There's a reason we do that, but regardless, I'd say we tend to do our septums in the OR which then says, "What can we do in the office to help you?" Then you start saying from a pure nose standpoint, we can reduce the turbinates, typically the inferior and the septal turbinate. The valve, basically, we assess, we evaluate and we say, "Boy, that's a backburner issue." We talk to our patients who have those issues, meaning that it's more of an uphill battle. In my hands with all sorts of techniques and technology through the decades that I've been doing this, I cannot achieve consistent results with nasal valve issues, whether internal or external. I can't.

It's very nuanced. It's a real thing. I'm definitely on the side of the fight on the valve that it is an issue, but if you address the internal issues first, the likelihood of you needing to address that valve is minimal. There are valve maximalists who say every patient who has a nose problem has a valve problem. I've seen it too many times with our patients where you see somebody with a valve issue, you see somebody with obstruction internally, you correct the internal obstruction, and they're fine. They don't need anything else, and if they do need something else, focusing on the nose, that's our algorithm. If somebody has valve collapse or narrowing there, then it's something we identify, we talk about, we say, "We're going to get these internal issues corrected in the office and we're going to see how you're feeling." If you're feeling like you're where you need to be, wonderful. If you're not, it depends on the situation, but we might consider VivAer or LATERA rarely. We don't do a ton of rhinoplasty at this point, so if somebody really needs that functional rhinoplasty, we've got folks we can tuck them in with. That's the nose component.

From a sinus component as it relates to anatomy, it's evaluating their scan, evaluating their symptoms, evaluating their history, and putting that all together. The most common treatment that we'll offer for our patients who have sinus issues is balloon sinuplasty for the maxillary and frontal sinuses. The thought there is that common sinus outflow of tracks, of frontals coming into anterior ethmoids, maxillary is coming into anterior ethmoids.

That area, if it is tight, if it is even slightly compromised, that's a domino that once it starts tipping, is going to start clipping off downstream. If we can get those areas open, it's helpful. What I said out of the gate, nose and sinus anatomy patent, that's the most key area. If you have basically adequate outflow, adequate airflow into those areas, that impacts actual nasal breathing, which is a very controversial thing for me to say, but it's true. I see it all the time. It also just impacts the health of the nose and the sinuses.

Our most common treatment is balloon sinuplasty for the maxillary frontal sinuses, turbinate reduction, nasal swab body reduction combined together. We're coming to that conclusion after evaluating all of these specific possibilities for a patient for whom they've got a deviated septum. That is something that, if you didn't correct that, you're not going to help this person, we'll do that right out of the gate kind of thing. There's a mindset and a likelihood about how we practice, but every patient's unique and every clinician needs to make sure that they know that they're in control, and they can do it if necessary.

[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 running 13 other-

[Madan Kandula MD]
Yes, correct. My full-time job is that.

[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.

[Ashley Agan MD]
Do you ever have patients who are wanting to continue to see their doctor for medical management? Do you have to be like, "Hey, that's not really our model here, so and so's going to take care of y'all"? Because I have some patients who just cling to me and I'm like, "You don't really need to see me for this anymore."

[Gopi Shah MD]
I would cling to you, Dr. Agan. I’d be like, "There's only one person going in my nose.

[Madan Kandula MD]
There you go. Maybe you're clingable. Maybe you are just that appealing.

[Ashley Agan MD]
Simple things that are like, "We're just going to follow up in a year with an audio to follow with some hearing loss." We have advanced practice providers in our clinic that would be perfect to pass off to but patients are like, "Can I see you? Am I going to see you?" I'm like, "Sure."

[Madan Kandula MD]
That's what I was going to say. The hardest two letters in the English language are N-O. You don't need to be a jerk about it. Meaning that I think the challenges are there. I hired my first physician assistant in 2009, so about five years into my practice. When I brought her on, her name is actually Ashley, and she was great. That's why I'm sure you're great as well because of your name, but anyway regardless, when we brought her on board, it was a big deal because everybody expected to see Dr. Kandula because, you know what I'm saying?

I had to figure out a way to preserve my sanity and that was by letting her do things that she should be doing and saying no sometimes. Believe me, I got my ass chewed out by more than one referring doc, who basically in unkind words said, "If I'm going to send a patient to you, they're going to see you, or I'm not going to send patients." In private practice, what do you do in that situation?

You either say, "Yes sir, I'll do what you say," or you say, "I'm trying to turn the other cheek as much as I can" How I approached it was listened, understood, and then I think we had a little bit of a unique pathway for those couple of docs for a while and then I said, "Screw it. We're just going to do this and I know some people aren't going to be happy." Back to our patients today, they know, they understand, they actually like our medical ENTs oftentimes more than they like our surgeons. Not that our surgeons are not good people, it's just you'll be amazed yet to see how clearly people can understand things that make sense, and it makes sense when you have easy access to a provider who's going to give you good care. You generally aren't going to complain about that. That's true for our patients. They know it's a team-based approach. They know our surgeons are always available, so if something's going on where somebody needs us, we're there.

The only way we're able to make that happen though is, back to preserving our surgeon, preserving our medical ENTs is the only way we can make sure that our surgeons can be available when things are hitting the fan is that they literally are available, and so that means we don't get them tied into doing things they really shouldn't do. It starts with somebody setting boundaries and parameters, which as physicians, in particular, nobody teaches us to do those things. Sometimes for us at ADVENT, it's having a system that forces us to do the right thing in that situation.

(7) The Hurdles of Providing In-Office Procedures

[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.

Honestly, most of our colleagues are literally not allowed to do these procedures, not because of the medicine, but because they work in systems that literally will not allow their docs to do office procedures. Try to think about fighting that battle and you're not going to win. Honestly, you think about like an academic medical center, you're not going to win that battle. You're not going to convince the powers that be that it's better for you, little ENT, to do this procedure in your office versus we got an OR, we got an anesthesiology staff, we got nurses. They're sitting there waiting for you, and the economics are better for us. When you take that patient to the operating room, good luck to you, my fellow ENT colleague to try to convince them to do what's right medically, for them. I think I went in a lot of weird areas there but I'm just saying all those things intertwine. The only reason we can offer the care that we offer at ADVENT is that we aren't part of a system like that. We don't have bricks and mortar that we have to justify. We don't have a CT scanner that's sitting in the basement that the system wants you to send your patients to.

We can make choices, our patients can make choices. Those little decisions over time, it's not quite 20 years, but over time, it's just simply saying, "What's the right thing for a patient?" In-office imaging, is that right for our patient? Absolutely, no question. I don't think anybody would question that concept. Office-based procedures, is that the right thing for my patients? Absolutely. Home sleep testing, absolutely. Oral appliance therapy is something we offer on-site at our clinics. Is that the right thing? Absolutely. You just think about it and you just go one after another and you say, "Yes, yes, yes."

When your fate is controlled by your knowledge and the actual medicine, the barriers that pop up are things that you just figure out a way to either blow over or go around or go over. I think in medicine in general, we've lost that skill. We don't know how to fight for ourselves. We don't know how to get things done anymore and it's a problem. That's happened over my career. Honestly, when I came out of residency, it was still back in the area where if new technology and new treatments were coming along, your goal was to figure out if that was the best thing for your patient, and then you'd adopt it, and you'd fight to make it happen. Now, those battles can't even happen anymore because all too often, our colleagues are no longer in control, it's the suits that are in control. We did it to ourselves is the reality.

[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.

Strangely, back to the earlier conversation or an angle on this is that very same patient who is denied in-office balloon sinuplasty oftentimes more often than not, the insurance will approve a sinus surgery in an operating room setting. That might be a road to go down, depending on the severity of somebody's disease state. Which just seems obscene to me, insane to me but that's the case. It makes no sense at all. Healthcare insurance doesn't need to make sense, but that one is like, "How do you explain that to somebody?" Literally, people are like, "You're telling me they would rather me go under anesthesia and go into the operating room than have this done in the office? That's what you're trying to tell me?" I'm like, "That's what I am telling you." They're like, "That's insane." I'm like, "Yes, that is insane. You might want to reach out to your insurance company to talk about their mental health because literally, that's insanity. It doesn't make any sense" Part of it’s because nobody ever calls it out. It's insane, and we see this all the time, but who can you talk to about that?

You're not going to get anybody's ear at that insurance company. They don't care. They literally don't care and it just boggles my mind sometimes. Part of my hope, and I'm going to do a better job of this moving in a forward direction, is I think if normal people heard the crazy things that we all experience just being physicians and surgeons in this country, it's mindbogglingly unbelievable some of these things. Part of the reason these things exist and they continue to exist is that people don't hear about them, they don't. Everybody knows things are screwed up in healthcare in this country, but they don't know that it's this screwed up, but it is.

[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.

I can honestly say from my conversations with industry, all aspects of industry as it relates to our specialty, because many of those folks come from ortho and neurosurgery and other things like that. Consistently when I broach this area of conversation, they're always like, "What the hell is up with ENTs? You guys are weird." Literally, because it's like we are surgeons and yet we have this, I don't know what it is, that we have this mindset of self-loathing. It's not just our colleagues talking to ourselves, meaning that there's this constant chirping of, "That person does a lot of in-office stuff and what's wrong with them and blah, blah blah. I know that medicine is the right way to do it."

People have a lot of dogma generally speaking, but in other surgical specialties, we don't have as much dogma as we do in ours. I don't understand where that comes from. I'm just going off on a tangent, but I'd say back to our industry colleagues, they are flabbergasted that we as a specialty have been so slow to adopt office-based procedures, when it's what patients want. The technology's there, the economics make sense. The only people standing in the way are ourselves. It's ENTs standing in the way of us doing things and when you break it down, the truth there, in my humble opinion is the truth there is, I guess I, just to go full circle back to how we were all trained. I was trained in an academic medical center. In an academic medical center, there's a construct that exists there that is, OR first, hospital first. We all work for those things. We are subservient. Then you go out in the real world and you find, no, actually it's not OR first, and it's not hospital first, it's patient first. Patients don't want to go to the operating room. However much you want to go to the operating room and however much you like to operate, they don't care.

When you give them the choice between the office or operating room, and if it's truly like, "You could go down this road or that road and both are going to be good options for you," they will choose office every single time. Other than if somebody's squeamish about office, but if you know what you're doing and you do enough, you can pick those ones out of the crowd. Regardless, the reason that we aren't doing more office procedures isn't because the demand isn't there and isn't because the economics don't work, and isn't because the technology isn't there. It's because the system, the status quo is rigged to direct people towards the operating room, direct us to think that we need the operating room as that's the only place I can really be comfortable and operate when in fact you can do this in the office. There's no doubt about it.

[Gopi Shah MD]
I just have two quick questions, then we'll put a pin at it as Ash likes to say but in terms of oral appliances do you have a dentist that you work with?

[Madan Kandula MD]
Basically historically we've had dentists that we work with. We've been doing that for a decade at this point, but currently, we're challenged because we've got multiple clinics right now. So we've had a hard time finding dentists in each metro area that we're in. We're looking at trying to just bring that in-house. There's a whole podcast episode on this, so I'm not going to go into all the details. Let me tell you this, oral appliance therapy is something that patients want if they could have access to it. The place where they could have access to it is actually within an ENT office.

That is a big paradigm shift, but the challenge for dentists who are passionate about these things, sleep and sleep dentistry, is they're on the other side of the fence from the health insurance industry. The health insurance industry doesn't want dentists. They don't want to break that wall down because as a whole, once we have dentists and now they're billing through healthcare insurance, that's going to create like “the end of the world” kind of thing. Anyway, all I can say is that our patients at ADVENT, the large majority of the folks that we diagnose with obstructive sleep apnea if given the choice between an oral appliance and a CPAP machine, will choose an oral appliance when they're appropriate candidates. I believe it is my duty to figure out a way to make that possible. It's the same conversation as office versus OR. It's not what I want to do, it's what do I need to do for my patients. In this situation, if patients had that option, they'd be choosing it way more often than they currently are. I'm done sitting and waiting around for somebody else to solve this problem. We are helping to solve the problem in our clinics. We're not there yet. It's actually one of the initiatives that we launched this year and it's rolling right now.

It's a passion project for me, which means, that's a good example for me personally of a situation where I am going to take that ball and I am going to drive that forward. There's people I've had to run over and companies I had to run over and feelings that have been hurt and so forth and so on and I don't care. It needs to be done and we're going to do it. Once we do it, maybe I'm wrong. As forceful as I sometimes sound, maybe I could be wrong, but I don't think I am. I've just seen it so many times. Then I go full circle to this conversation I’d say, “Imagine a world where you have these folks who have breathing triangle issues and you could in a simple manner, get their noses working, get their airways open when they're sleeping at night in a elegant, simple, effective, efficient, so forth and so on.” That's possible today. We don't have to wait on somebody. Back to my simple turbinate reduction. I'd say, "Give a turbinate reduction and give me an oral appliance and give me a world full of people with breathing triangles that are broken."

That's not the right fit for everybody. I'm not saying that it is, I'm saying there's a lot of people who would benefit from that, who just simply don't have access to those options right now. Not by their choice, but because that's how the system is created or it's constructed right now.

(8) Working with Pediatric Populations

[Gopi Shah MD]
Then my final question. What's the youngest that you see in your clinic, specifically for the breathing triangle? I'm the pediatric ENT, I get to ask this question.

[Madan Kandula MD]
Basically, currently we'll go down to 12. When I started the practice, it was birth to death, basically. We treated all comers. Again, there's a whole episode here and I know you're a pediatric ENT. Let me tell you something, the folks that break my heart are kids who have issues in these areas. Breathing triangle issues. They're mouth breathers. They have sleep apnea. So forth and so on, their noses don't work. Their throats are too tight. Our adult sleep apnea patients, most of them started as children whose noses didn't work, and what that ended up doing is creating a domino effect where their airways basically collapsed down on them.

It's a whole conversation and our dental colleagues are so much more advanced on this than we are, especially our specialty. The construction of your airway is part and parcel or has to do with the construction of your maxilla and your mandible. If those are not appropriately constructed, if they're too tight for your body, that's where you get nasal obstruction. That's where you get chronic sinus issues. That's where you get sleep apnea. If you can address it at the source, which is kids who have these issues, you will, back to unlocking potential, there is no greater potential than the children in the world and in our country. To see those kids suffering and who are going to turn into adults whose lives are going to be negatively impacted by this stuff, and know that I could do something about that because there's something I could do and you could do, maybe I can convince you to do it, but I don't have the bandwidth to do it right now. Very simply, back to those kids who have breathing triangles that don't work, they're mouth breathers, I go back to the same core concepts of is it an anatomy issue? Is it a lining issue? It's an issue. Do not sweep it under the rug.

Pediatricians should know about this stuff. If a kid is mouth breathing, if a kid is snoring, their airway is literally crying out for you for help. Answer the call. Now, what does that mean? What does it mean to answer the call? It probably actually doesn't mean a tonsillectomy. It might. It very well may be, establish a patent nasal airway. Maybe it's an adenoidectomy, maybe it's a turbinate reduction in a little kiddo. Make sure they've got anatomy that's patent, nasal anatomy that's patent. That's a good starting point, depending on how far gone or how long these issues have been going on. Orthodontists, who can do expansion of the maxilla, that's so easy in low single-digit kiddos. They just need to be connected to the right resources. Again, I could go on and on about this one but I wish we had the bandwidth to help those little kiddos. Gopi, maybe you will take the mantle up at this point, but if you don't, someday I promise once I have the bandwidth, I'm going to get there, but just today, I don't have it. All I can do and I'll do it here, I'll do it wherever, but I think all I can do is add to the chorus of those folks who are concerned about these issues in kiddos. That's where it starts and I wish it could just end there. You'd bend the arc of time and the lives of those individuals in a profound way.

Back to what I was saying before about the impact and reach of our specialty. This is the area, the breathing triangle. These issues are the issues that have more downstream impact than anything else in our specialty and the solutions and treatments are so simple. If we can just focus on the things that are, if you believe that to be true, maybe you don't. I don't expect everybody to believe it, but if you don't, all I ask you is please entertain the possibility that it might be that way. Once you start seeing it that way and maybe you'll start doing some things that way, you'll start seeing how big the impact can be. That's my long answer to that question, but it's an entire podcast episode by itself. Absolutely.

[Ashley Agan MD]
I have so many more questions and I wish we had you for a little longer, but it probably is about time to land this plane as we say. Thank you so much for taking the time. Is there any parting words or any take-home points? In addition, do you want to leave listeners with any resource as far as website, social media contact? Where can people find out more about you and ADVENT?

[Madan Kandula MD]
I know it sounds hokey, but it's adventknows.com, either K-N-O-W-S or N-O-S-E. Don't matter. That one's easy if you want to find out about the practice. Me personally, I'm trying to be better about this, but currently, I'm most visible on LinkedIn. Madan Kandula, just my name, madankandula.com is a place to go. It's probably pretty sketchy and it might go to some weird internet places, so be careful on that one. I think conceptually if people are interested or intrigued in some of the stuff that we were talking about, I love talking about this stuff and would be very happy to have conversations.

More importantly, I don't mean it to be this way, but I'm just going to do it is, we are where we are and we're growing and what we need more than anything right now is to find ENTs who understand what we're doing. We need to add more, we want to grow further and the only way for us to do that is for our colleagues who are out there who maybe what we just talked about was interesting for them, reach out to me and see if we can help. Maybe if enough of our ENT colleagues reach out to me, maybe we can actually get to those kiddos that I was talking about before.

Regardless, I'd say and even if you're not in ENT, certainly, this is something that I'm passionate about, that we're passionate about as an organization. For our dental friends and even other specialties. A lot of other specialties are really interested in this breathing stuff, more so than us. I think there's a movement that's starting to get created. I do not know if you guys have heard of the book Breath, but that book came out a couple of years ago. That's a book, for those who are wondering, "I'm not quite sure what he's talking about." Go read the book Breath. It gets a little like Zen after a while. I think the first part of that, which just simply talks about airways, is talking about the breathing triangle. That's maybe a good example but long story short, I'm available for people who are interested in this stuff and ready and willing, and able to keep the conversation going.

[Gopi Shah MD]
Thank you, Dr. Kandula I appreciate it. I'm going to check out the person looking back at me in the mirror. That's the first thing.

[Madan Kandula MD]
Perfect. Thank you. I appreciate it.

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 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.

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