Sometimes conventional healthcare doesn't provide the personal care you deserve. Check out this week’s episode of ADVENTing to learn why we’re here for you every step of the way.
Dr. Kandula: So basically there are stories that we hear every day, every 15 minutes during the day, from our patients, for those who didn't connect the dots there. Patients tell us their stories, and their stories are so consistently frustrating to me, and I think to anybody here who cares, which is everybody, that people suffer with issues that they don't need to be suffering with. And the challenge for us is that there are so many nuances, so many different stories and so many variations on similar themes that I would venture to guess that I think there are a lot of people out there who feel like they're alone. A lot of us. And the truth is you're not alone. You're not alone in being frustrated with unfortunately I think you're not alone in being frustrated with a health care system that sometimes, really more often than not, doesn't work well for people who have issues with lung, nose, and throat.
Dr.Handler: Patients wanna be believed.
Dr. Kandula: Sure.
Dr. Handler: Like that is, to recognize that they, what they are feeling is true to what they're feeling and what I believe them or you believe them, or the other providers here believe them, that's powerful, and I think that it's meaningful, because a lot of patients come here and they have tried gazillions of things, and maybe have had imaging or whatever it might be, and are like, "I'm sorry", you know. They're made to feel like that's not real or that nothing can be done about it. That's frustrating. It's frustrating for me to hear, it's frustrating for patients, and so it's validation that what they are feeling is true to what they're feeling.
Dr. Kandula: So how many patients do you see that have been seen elsewhere for the same issues? Not necessarily ENT, who'd been seen elsewhere.
Dr. Handler: Oh gosh. Well over 90, 95%.
Dr. Kandula: Like, kind of everybody?
Dr. Handler: Right. Because I mean, these are common problems for normal people out there trying to live their lives that are suffering with issues that can be addressed, because, and this is the thing that I've learned. Coming to ADVENT and thinking before is that you can either do something or you can't as a surgeon, right? We trained to do things to help patients, and so we can either say, hey, we're willing to try something that can make a meaningful impact in your life, looking at all options, you don't have to do anything, right? I mean we deal in the quality of life for the most part, yes, we're treating severe sleep apnea and obviously, it has long-term consequences, but it's taking, rather than a hands-off approach and saying, I'm sorry, there's nothing else I can do, you just have to live with this or, these are the things that we can do. These are the options. They can get real invasive, but it can also get real less invasive.
Dr. Kandula: Right. Although even it's, stopping it the very first thing, so. Not everybody that we see has been seen elsewhere. Meaning they've gone to the primary care doc, they've gone to urgent care, they've gone here, they've gone there. Many folks have gone to see an ENT and how many of those patients that are suffering that have gone and said, oh there's nothing to do, or maybe they've had stuff done that just hasn't been effective, but most often than not, they've just never had anything done. Then the next question or reality is, how often is there something that can be done that's actually going to help them?
Dr. Handler: You mean that's potentially still we can do something to help them?
Dr. Kandula: Yeah, that person who's been dismissed everywhere else, they come in. First thing is just listening to what they've got going on.
Dr. Handler: Validating that their experience is real.
Dr. Kandula: But then how likely is that patient actually right that this isn't right, this isn't the way it's supposed to be. They've been told this is, hey, this is it, buddy, this is your life. Here's the Flonase, have a good life kind of a thing. And they should be pissed off, and it's unacceptable, it's dismissive, it's the opposite of any possible reason I got into this, into medicine to begin with, is the norm everywhere else. And it, for the life of me, I've never figured out where that's coming from. Other than, it has to be, I think, out of ignorance. Ignorance not on the part of our patients, because they're generally right. Ignorance on the part of other providers that either don't care or can't do anything or both of those things, but I just haven't figured it out.
Dr. Handler: I think it's ignorance--
Dr. Kandula: It's frustrating.
Dr. Handler: And it's fear. I mean, if, you know, again, and this goes for any doctor, to be honest with you, out there and maybe this is getting too deep into physicians, but surgeons especially, but even other docs will direct you towards things they feel comfortable doing. There's always a bias to push patients towards you know, hey, there might be five other ways of doing this procedure that are better, but like I didn't train that way. I don't feel as comfortable 'cause I'm not as experienced, so I'm gonna go ahead and kind of like pitch you kinda this way of doing something to treat your knee problem or who knows. I mean it could be a gazillion things, and you can take that and make an analogy for the nose. And there are some ENTs that feel very comfortable doing sinus surgery and there's some ENTs who don't feel very comfortable doing sinus surgery, but as a patient out there in this world, you're never gonna be able to get through this filter for the most part, unless you have some sort of background knowledge of who is the person that you should see to do X or Y. And so, that's kinda a long thing, but like, you know, patients coming in that have been told there's nothing to do. I would say out of all of those patients, maybe 90, 95% of patients, you can do something, and still improve upon what they told, sorry.
Dr. Kandula: So the patient that's coming in frustrated with their nose. So let's say that's their complaint. Their nose is stuffy, they've got recurrent sinus infections. Those issues, if somebody's got a nose or sinus issue, it's one of two issues. What are those issues?
Dr. Handler: It's either anatomy or it's lining.
Dr. Kandula: Period. End of story. End of sentence. Nothing more. So for somebody who is frustrated with their nose, it's anatomy or it's lining, and anatomy issues cannot be treated with medications. Correct?
Dr. Handler: Correct.
Dr. Kandula: Lining issues might be, most folks coming in to see us, they've tried this, that and the other thing that hasn't really helped them. Most folks who are suffering with nose issues and sinus issues, it's actually a combination of both of those things. Anatomy or lining. So when somebody comes in to see us, our goal and role is to get an understanding about their situation, understanding about their anatomy and lining, and then talk through the different options to come after that. And for whatever reason, that simple concept of, you know, the anatomy and lining issues hasn't, it didn't get taught in med school, apparently. Didn't get taught in ENT residency, apparently. Because a lot of folks are walking around with anatomy that's compromised, that there are simple things that can be done to help it, that never hear about those simple things.
Dr. Handler: And who else is gonna make an impact on anatomy if it's not an ENT surgeon?
Dr. Kandula: Right.
Dr. Handler: Otherwise what, we're just, we are no different than an allergist or a primary care or family practice or OBE who's treating the nose or whatever it is. 'Cause then like, okay, then we basically just truncated what we can do and we're no different than anybody else.
Dr. Kandula: Right, so if somebody's going to have surgery on the inside of their nose, the person doing that surgery is an ENT. Like it has to be an ENT. Which means it has to be us. That's our specialty.
Dr. Handler: But if we're not willing to do anything and we want to tell patients I'm sorry, there's nothing else we can do 'cause we don't wanna address the anatomy then where does that leave that patient?
Dr. Kandula: Which gets back to the fundamental frustration that's my frustration, that's our patients' frustration, is, you know, why doesn't everybody wanna help folks? And I think, unfortunately, I think that the way that things, I don't know, I don't have the answer. I don't have the answer and I think the answer that I can deliver is that it's not the way it's supposed to be. It shouldn't be that frustrating to get good care.
Dr. Handler: Well and I think again it leads into what do you feel comfortable doing? Because we are in a place, we've talked about this, that's independent, we can decide if we wanna do things in office, we can offer things that other systems can't offer. We are lowering risk to do things in an office setting for patients that again can have a great impact in their lives at a less invasive cost essentially. To start doing something for somebody versus taking them to the operating room, it's a big deal for patients and, you know, as a surgeon who's been on the other side of the, who's been a patient myself and had surgery done you know, it's scary, and so patients I get don't wanna take a leave to go to the operating room 'cause you know you're put to sleep and you have downtime and it's just this whole other thing and surgeons, you know, that's not taken lightly and it shouldn't be, and so surgeons may not feel like, hey, to try and just move the ball maybe a little bit down the field or what they might believe is moving the nose down the field a little bit, you know, that might not be worthwhile risk to them, which is why they maybe take a hands-off approach. Whereas if we say, hey, look, let's try something in the office, it can have a big impact. Worst case scenario is it doesn't get you as far as you wanna go, we can still do other things as options but that's the worst-case scenario.
Dr. Kandula: Yeah.
Dr. Handler: You know, it just, again, it's just, it comes down to what one feels comfortable doing, and I think that as surgeons we have to be willing to say yes, I'm willing to try something, because a patient's suffering and they come in and who else is gonna help them then if we don't step up?
Dr. Kandula: Yeah, well, and even that fundamental, so if you've got a nose issue, you've got a sinus issue, you've either got an anatomy issue or a lining issue, period. If you have both of those issues, if you don't address the anatomy issue, you can use all the medications in the world and it's not gonna help the lining. And how the rest of the world operates is flip opposite of sanity and reason is that they will try to spray and pill you, you know, try to hit the lining with medications when the anatomy is shut down and so flip that around, if someone's got an anatomy issue and a lining issue and we can get the anatomy open, especially if you can do that in a low key manner, let's do that and let's see how the lining likes that. And the lining generally likes it when the nose is open and the sinus passageways are open, and so for most of our patients, our goal when we see somebody is to get them better, and better to me means if we can do something that's going to fundamentally get them on the right pathway to minimize the use of medications, including antibiotics and other things, that's the path that we would want them on. And part of it is, that's the path that I would want. If I have a choice between, you know, sort of putting band-aid after band-aid on a situation that I know could be resolved without a band-aid, with something that's actually gonna get to the root of the issue, get to the route of the issue. And if I need a band-aid on the back end of that, fine, but don't sit and tell me that, here's a band-aid, here's a band-aid, here's a band-aid, don't tell me that that's an appropriate approach, 'cause it's not.
Dr. Handler: And it's not without cost. Literally cost to buy all those medications. What does it do to a person who's taking, think about how many patients we have that come in that have their combination of pill, whatever it might be, that they take daily maybe throughout the year or just during allergy season is their Claritin D and whatever else it might be, right? I don't know what impact that has on the body systemically. And, you know, we're in a day and age where we don't wanna load our bodies up with medications unnecessarily, and I get why they're doing it, I get why they're doing it, because either someone's told them that's what they should do or they're grasping at straws to try and figure out like, how am I gonna get a little better in my nose so I can kinda manage. So I get it, but I feel like it's a win for us if we can get their nose working without having to have any of those medications and oftentimes they don't need them anymore. You know, get them breathing better and then they can stop buying all that stuff.
Dr. Kandula: Is there somebody, are you, may I ask you a simple question? How many medications would you wanna take?
Dr. Handler: Zero.
Dr. Kandula: That's my answer too. Are there people walking around on this planet that want to be taking one, two, 10 or 50 medications?
Dr. Handler: I can't imagine.
Dr. Kandula: Because that's how the health care system is set up right now. And so for us, you know, I'd say, what's our bias? Everybody's biased, everything's got an angle, our angle is, from a nose standpoint is, if it's blocked, let's get it open. If it's open and we need to use medication, let's use medications. But let's not throw medications at an issue that needs--
Dr. Handler: And let's stack them, right?
Dr. Kandula: But who would want that? I don't want that. I don't want to take anything I don't have to take, period. End of sentence. Like, there's not another sentence. If I can avoid it, let me do that. Now if I don't have an issue, then, you know, leave me alone. If I have an issue, so say your issue is that your nose doesn't work, your nose is blocked up, and you are, and maybe we're insane here, but you are in the same mindset as us, as boy, yeah, my nose is blocked up. What do you want? You wanna breathe better. Okay, you wanna breathe better. What you're not asking, you're asking for a solution of I wanna breathe better. You're not asking for, you know, all the things I can throw at you medication-wise to, how do you say this, to sort of help a little bit, you know what I mean? Like, we can stack 'em, I can give you this, that and the other thing and it's still never gonna get you as good as you could be if you could just breathe properly, but that's what we're gonna do for you.
Dr. Handler: Think about how many of those patients have not had scans. We talked about, why do we get scans, why do we have scanners in our office? So that we can be able to get that on a patient to answer questions about what's going on with this blueprint here.
Dr. Kandula: So to answer that for those, so a scan is what? X-ray, images.
Dr. Handler: Correct.
Dr. Kandula: So if somebody's got, the only way to figure out if somebody's got an anatomy issue in the sinuses and some parts of the nose is with--
Dr. Handler: A CT scan of the face, right? Imaging.
Dr. Kandula: Imaging.
Dr. Handler: Yes.
Dr. Kandula: Is there another way that you know how, know of? There's no other way.
Dr. Handler: Correct.
Dr. Kandula: So if you are gonna have a nose procedure done, and you've never had imaging done, how do you know that there's not something going on outside of the nose?
Dr. Handler: We don't. I don't.
Dr. Kandula: So if your nose was at stake. Say you were getting set up to have, say you've got a deviated septum, which you might in fact have.
Dr. Handler: Which I do, but I wanna touch on that in a second but go ahead.
Dr. Kandula: Yeah, so say you've got a deviated septum. So we look in your nose, to find out if someone's septum is deviated, we just need to look at your nose. To correct a deviated septum, we need to take you to surgery. Not a big deal, we can do that. If you had a deviated septum, because you have a deviated septum, does it mean that you don't have issues elsewhere in the nose and the sinuses?
Dr. Handler: No.
Dr. Kandula: And if you had issues elsewhere, if you had the choice, would you like to have those issues addressed at the same time you had your septum fixed or a different time?
Dr. Handler: At the same time.
Dr. Kandula: Would you want that information before surgery or after surgery?
Dr. Handler: Definitely before surgery.
Dr. Kandula: Are you insane or are you sane?
Dr. Handler: I'm sane.
Dr. Kandula: Are you like every single other person walking around this planet, I think? But that's not the way it's normally done, correct?
Dr. Handler: Right, so how many patients have you seen, whether they've been operated on before or not, and you say, hey, have you gotten a CT scan of your face and sinuses, how many of them say yeah?
Dr. Kandula: No. I mean, it's crazy. It's crazy to me how, what the, sort of the standard is out there. Now we have the benefit of office-based imaging. Why do we have office-based imaging?
Dr. Handler: Because it allows us to get patients access to understand a blueprint.
Dr. Kandula: And us.
Dr. Handler: And us.
Dr. Kandula: Right, like I don't, I'm not a magician, I don't think you're a magician, I can't see in the areas I can't see without imaging. With our office-based imaging, so we, every ADVENT office has a CT scanner, low dose, meaning like low radiation dose, which is what we want. Images are immaculate, which is what we want. We need to be able to see, if you can't see, you can't know, if you can see, you can know, and once you know, then we can have a conversation about what we choose to do or not to do about that information.
Dr. Handler: But that's also why we have a scan, look, it's not like a patient can't go somewhere else to a hospital and get a CT scan, but what's essential as part of our visit with the patient is you can get a scan here, we can review your scan immediately.
Dr. Kandula: Right
Dr. Handler: Right, you're not having to schedule a follow-up appointment for that and run around the world trying to figure out where you can get in and wait at some other office or hospital system. So it's a matter of get that scan, communicate with your surgeon, walk through that scan together understand what that blueprint is, and then come up with an attack plan essentially.
Dr. Kandula: Is there somebody that you, is there somebody that you know, if there was somebody that you know who was getting set up for surgery on, let's go back to the septum again, that didn't have imaging, would you make sure they got imaging before they did that?
Dr. Handler: 100%.
Dr. Kandula: Yeah.
Dr. Handler: 100%.
Dr. Kandula: There's not a count, there is no counter-argument against it other than I don't want the info. I guess the only counter-argument I can think of is I don't want the information because we're good here.
Dr. Handler: Well it's because we've seen too many times on the back end of somebody having septum done and still having nasal congestion. Their complaints are no different, maybe they get better for a month or two and then they get back to their baseline because, and this was what I wanna touch back up on, every patient has a deviated septum. This is the secret of ENT, right? So what's communicated out there in the world when primary care looks in your nose and patients have in their heads, for a good reason, because it's communicated this all the time, is that you have a deviated septum but I've never seen a perfectly straight septum. Never in my lifetime, okay? And so the reality is how bad is that deviation, where is that deviation, that's what matters. And so if you assume, rightfully so, that every septum's deviated, likely it isn't the problem a lot of the times.
Dr. Kandula: So to recap there, if you come in with a complaint that you can't breathe through your nose and we look in and we see that you have a deviated septum, does that mean the deviated septum is the cause of your block or your problem?
Dr. Handler: Definitely not.
Dr. Kandula: It could be.
Dr. Handler: It could be.
Dr. Kandula: It may not be.
Dr. Handler: Correct.
Dr. Kandula: So, you know, but the typical practice is you can't breathe through your nose, we see that your septum is deviated, let's fix your deviated septum. Which might work, might not work. Our approach is you can't breathe through your nose, we see that you have a deviated septum, that might be the tip of the iceberg, there might be other things that are there and oftentimes, much more often than not, I'd say, well, much much more often then not, if somebody has a deviated septum there are often, often, oftentimes things we can do in the office that are much less intense then straighten the septum and achieve that same goal. If the goal is to breathe well through your nose, then we want you to do that, and if somebody needs their septum straightened, we can certainly do that, but if it's a matter of you wanna breathe through your nose, we'd rather sort of not go through a big surgery if we don't have to, we can do that.
Dr. Handler: Right, and I tell patients all the time, I like doing septum surgery. I do a lot less of it now.
Dr. Kandula: Sure.
Dr. Handler: 'Cause I just don't need to address the goals they have which might be nasal congestion, their breathing, and it's a lot of what we deal with and so, hey, if I need to address the septum, I'll do it, not a problem, but like, the reality is I do a lot less 'cause I don't need to do as many more 'cause that's not necessarily how we get the win for patients.
Dr. Kandula: Right. Yeah, it's just the end goal in mind, which is, okay, that somebody's got a breathing issue, let's get that better and let's do that in the lowest key yet most active and proactive manner possible and that oftentimes, and it's not, but for us and our approach is, let's not bury anything, let's bring everything to the surface, let's get all the information out there in front of us and then let's make an informed decision. We are the guides so we're gonna help you understand what this information means and then, you know, again, if somebody's got issues with their nose or sinuses, there's often many different options there running the gamut from doing nothing, maybe medications, that's usually not kind of our big go-to option for most of our patients.
Dr. Handler: Well, 'cause most of them have already been all through all of that.
Dr. Kandula: Most of them have anatomy issues that aren't addressed, and so yes, can we prescribe antibiotics? Yeah, we can do that. Can we hand you Flonase? We can do that and there are times where it's appropriate, but it's not appropriate if the anatomy's shut down. And so let's keep that in sequence, let's understand, we gotta be able to see to understand. Once we understand, we gotta be able to do. We can do with the best, and if we can do, let's do in the manner that's most aligned with how somebody wants to be taken care of and it's really, the nice thing for us is how our approach has been structured is for the sane, it is for the average person, it's for me, it's for you, it's for everybody out there, because we're doing things, we're approaching it in the manner that I want it approached, you want it approached, you want your kids, you know, I would want this approach for everybody and anybody, which is why it's for everybody.
Dr. Handler: And it's not rocket science.
Dr. Kandula: It's not. But it's, even a rocket scientist can't do their rocket sciencing very well if they can't breathe well.
Dr. Handler: True.
Dr. Kandula: True. So if you wanna build the best rocket, breathe through your nose.
Dr. Handler: You better sleep well.
Dr. Kandula: Sleep well. I hope you're sleeping well. If I'm on your rocket ship, I hope you're sleeping well and breathing well.
Dr. Handler: Or if you're a pilot. Or a truck driver. And all these things, right?
Dr. Kandula: If you are a human being walking around on this earth, if you can't breathe properly, it's gonna impact you, whether you're a rocket scientist or a neurosurgeon I don't care what you do, but you're not gonna do it well if you can't breathe well.
Dr. Handler: Absolutely.
Dr. Kandula: Yeah. Okay, once again, all over the place.
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