Otolaryngologist Dr. Madan Kandula is considered Wisconsin’s thought leader for breathing and snoring/sleep apnea solutions. An expert in ear, nose, and throat medicine, his knowledge of healthy breathing has propelled him — alongside his wife, who is an audiologist — to found ADVENT, the largest independent ENT practice in Wisconsin, where they provide their patients with solution-based treatments without the uncertainty, dismissive attitude, and long waits that are often the norm. As such, he routinely treats patients who have had unsuccessful results from previous surgeries, and is often able to correct breathing issues with less invasive procedures. Along with his many other achievements, he is the first surgeon to perform balloon sinuplasty in Wisconsin, and the developer of a new model of care to evaluate The Breathing Triangle. Dr. Kandula is no stranger to these procedures, having undergone sinus surgery himself! In this episode, we dug deep into sleep apnea and related issues.
Tune in as Dr. Kandula shares…
- what The Breathing Triangle is, and how it applies to his work
- that if you have obstructive sleep apnea, you have a throat issue — 100% of the time
- the main foci of his practice: sleep apnea, snoring, nasal blockage, and sinus issues
- that he encounters many patients who feel frustrated because the healthcare system hasn’t worked in their favor
- that the success rate in treating sleep apnea is generally only about 30% — but with the proper interventions, it can be treated properly
- that he commonly treats snoring and fatigue (usually caused by sleep disorders like apnea)
- his approach: more integrative and root-cause-related, rather than putting a Band-Aid on symptoms
- that there are too many people walking around in this world suffering needlessly — who ought not to be
- that sleep apnea doesn’t discriminate based on age: it can affect anyone, at any time
- that our airways are evolving to be narrower over time, which is causing more breathing issues during sleep (as well as a host of other complications)
- that our environment has changed over time, exposing us to new allergens
- how he envisions change in the medical system — with a shift to preventive care that could save time and money
- why doctors are experiencing burnout in the current healthcare system structure
- how his practice treats sleep apnea, and how the approach to treatment needs to change
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Lauren: All right guys, thank you so much for joining us today. I’m here with Dr. Madan Kandula, who is the founder of Advent in Wisconsin and Chicago. He is an otolaryngologist, and he specializes in sleep disorders like sleep apnea — which I have — as well as other disorders related to ear, nose and throat. So Dr. Kandula, thank you so much for joining us today.
Dr. Kandula: Thanks for having me. I'll be looking forward to talking more about sleep apnea, and some of these other issues, too.
Lauren: Absolutely. Well, why don't we jump straight into it. Why don't you tell us about your area of work and your specialty.
Dr. Kandula: So, I'm an otolaryngologist, which is a fancy name for an Ear, Nose and Throat (ENT) physician. Obviously that covers those areas that are in its name, but it really covers head/neck issues. Head/neck issues other than the eyes and the brain specifically. We started as a general ENT practice, but we really are focused on what we call the breathing triangle, which is the nose and throat part of that. So if you take your nose and throat and lop off the ears, then you have a nose and throat. What we've come to learn, and what my patients have taught me over the 15,16 years I’ve been in practice is that those folks who have issues in those areas often have issues in both of those areas — and much of the time don't know that reality. So the nose and throat really are very, very much entwined. And if they are challenged in those areas, people do their best when we remove the obstacles in both of those areas. It's absolutely in our wheelhouse, from a specialty standpoint. Sleep apnea, which you mentioned out of the gate, is a throat issue.
If you have obstructive sleep apnea, you have a throat issue 100% of the time.
Not 99, not 98% … it's always that. But unfortunately, most folks who have sleep apnea never see an Ear, Nose and Throat physician. There are other physicians that can certainly help out, and I don't think this is too much of a rocket science approach … but if you have a throat issue, I feel, and our practice believes, that you should be seeing a throat specialist. And there are multiple options that come along with some of these issues. That's kind of the long and the short of it — we really treat sleep apnea, snoring, nasal blockage, sinus issues, allergies. And there's so many people who suffer with those issues.
Lauren: These are also issues that can cause a host of other problems. So are you talking about surgical interventions as the main focus of the practice, or are there other holistic approaches that you take as well?
Dr. Kandula: It depends. We are surgeons, so we do do surgery. Let me kind of walk you through the walk here … Everybody who has sleep apnea has a throat issue. If you have sleep apnea, there's three options: There's a C-pap machine, which is the machine you can wear when you're sleeping at night, over your nose, or your nose and your mouth. There's an oral appliance, which is like a retainer you can wear when you're sleeping at night; it just sits in your mouth. And then there are surgical procedures that we do on the throat, for the right candidates. When we see patients, though, the least likely thing we're going to offer somebody is surgery on the throat. There are certainly folks who are good candidates for that, but most aren't. Alternatively, for folks who have sleep apnea, snoring issues, if you've got a nasal blockage that is very common in those situations, then on that side of the fence, if you've got nasal issues, it's either anatomy or lining. So either things aren't open enough, or the lining’s irritated.
In that situation, most folks actually could benefit from simple in-office options, procedures, to get the nose more open.
Because medications don't treat the anatomy. So it kind of depends on the area we're talking about it. What we try to do is listen and understand what our patients are telling us; listen and understand the kind of the place that they're coming from — and try to match up our treatments to make sure things are fitting properly.
Lauren: Absolutely. And it sounds like, as you have mentioned, a lot of patients who have these kinds of issues aren't necessarily being referred to see an otolaryngologist or an ENT. So is part of the work you're doing about raising awareness of the need for overlap in these treatment areas?
Dr. Kandula: Yeah, absolutely. The first principle is that people need to understand more about these issues. These issues, as you mentioned before, don't affect just that one area. It really can ruin somebody's life. We see this all the time, and it's a massive domino effect. And we are guarding the first domino. So as that guard, as the person who's the gatekeeper there, literally to somebody's airway, my specialty and me specifically need to do a better job of getting the word out. And letting people know that they don't need to suffer. That's part of why I get on my soapbox sometimes … you see patient after patient that’s sort of mistreated unfortunately … how do you say it, people are frustrated and rightfully so because the system that exists right now, throughout this country, is broken. For somebody who has sleep apnea, the system doesn't typically work for them. When you look at statistics, if you have sleep apnea, the likelihood that you're going to find success with treatment is about 30% with a typical, pull-it-off-the shelf, one-size-fits-all approach; it doesn't work. But the thing that gets me going is that if you just have a little bit more thought put into it, the success rates go up massively. So it's just trying to make sure people are aware of some of these facts, and then letting people live their own lives and do what they feel is right. I think if you're ignorant because the information’s never been presented to you, or options have never been presented to you, then if I have maybe some information that might be helpful, then it's my job to get that information to you.
Lauren: Absolutely. And what about within your practice? What are you finding to be the most recurrent illnesses and symptoms that you're seeing among the patients who come in?
Dr. Kandula: It really runs the gamut. Because I think, theoretically, if you want to connect the dots back … if somebody has sleep apnea, the most likely reason for them to come in is because they're snoring and they're keeping their bed partner awake. That’s very, very common. But in addition to that, they might just be dragging through their life and not having the energy that they feel like they should have. And the challenge with sleep apnea is that it’s happening when you're asleep, and you're the last person to know that something's going on. I think it runs the gamut. Yes, we're an ENT practice; we have these specific areas of focus.
We see folks coming in seeking help for conditions that you wouldn't necessarily relate with ENT issues.
Even like the fatigue, as I just said; I don't know that most people would say, Oh, I'm tired, I should go see an ENT. You might think, I'm tired. I don't know what you’d do; you might want to do a whole lot of other things. Maybe you're going to be on the right path, maybe not. And then from a nose standpoint, we see a lot of folks with chronic headache issues, sinus infections … those sorts of annoying, ongoing, quality of life devastators.
Lauren: It's interesting, because it seems to me that allergies, nose issues, even fatigue … those are things that most of us would go to our GP first for care. Do you think it's a disconnect between the referral system as well, that perhaps GPS aren't always aware that any of those symptoms should probably be referred to an ENT?
Dr. Kandula: Yeah, I think so. I don’t like to point fingers. But I would say that system isn’t working really well, from a referral standpoint. I can only speak to my experience and say definitively, for the patients that we see here and we treat, far, far too many of them have been given multiple Band-Aids to try to stop a massively hurtful wound — and that's not right. There was a time where I sort of held my tongue a little bit more and tried to polite about it. At this point, I don't want to be rude about it. I don't want to be anything other than truthful and forthright — and just sort of letting it be known. Not all ills in the world are due to sleep apnea; that’s not true. But I'd say, there are more people in this world walking around and suffering needlessly than there ought to. Even one person who's suffering needlessly is one more than there should be. But we're talking millions of people whose lives are being impacted. When I get sort of heavy on this, is we typically think about this quality of life impact, which is significant. But if you have sleep apnea that's not getting treated properly, yeah, it's impacting your quality of life, but it will likely end your life sooner than it was supposed to be. Now the actual sleep apnea is not going to get you, but the heart attack or the stroke or the diabetes or the depression or those things will get you.
And so the challenge for me and the world around us is … somebody dies from a heart attack, and they had sleep apnea that was undiagnosed for 40 years, nobody typically connects it back to the sleep apnea.
They say, “Oh, it's sad that Joe Smith died at 50 from a heart attack. Isn't that too bad.” If it's true that Joe Smith had sleep apnea that was untreated or under-treated and he died from a heart attack, what’s true is that the untreated sleep apnea was that first domino that led to this devastating impact. And I think if that story was told, then everybody would be up in arms and say, “We need to do something about this!” But that story is never told. Not to be too rude or punny, but that gets buried away. It's a sad story, but nobody learns a lesson from it. And that's just not right, in my opinion.
Lauren: Absolutely. Well, what about the stigmas attached to illnesses like sleep apnea? We pretty much walk around the world, like allergies are a normal thing. But with something like sleep apnea, it's very interesting because I had that experience personally … as someone in their 30s getting diagnosed with sleep apnea, and being, like, I thought only old people got sleep apnea. How do we begin to break down those barriers of stigma, and allow people to understand that this is something that affects a much larger portion of the population?
Dr. Kandula: And the person that may be pointing the finger at you and saying, “What's wrong with you?” … they might have an issue as well, is the reality. It's such a common issue. I think that there is some awareness of sleep apnea these days. When I came out of training in 2003, and back 20 years ago, I don't know that most people would have heard of sleep apnea. Maybe a little bit. I think in 2020, most people have at least heard that term … “sleep apnea” or “C-pap”.
Lauren: It’s usually your grandpa has it. It's not like you do, right!
Dr. Kandula: Exactly.
But just to cut through some misperceptions, sleep apnea is not an old person's disease and it's not a young person's disease. It's a person's disease.
And another truth that I don't think people are aware of is that we, as a species … and this is where it kind of gets a little weird … as a species, our airways are becoming smaller. Which is why you're seeing so many people who have this issue. So when somebody has sleep apnea — just so all your listeners understand what we're talking about here — what that means is, that person is sleeping at night and their airway is shutting down. And when I say airway, I mean the back of the throat. So they're trying to breathe, their throat is shutting down, and therefore they can't breathe, They stop breathing, and then the body does something to wake them up mentally, or shifts position so that their airway opens up again. That's sleep apnea. So if your airway can take a punch, then okay, you don't have sleep apnea. But what's happened over time … and it's actually fascinating to me as a science geek … is that when you look at skulls … and you look at us now in 2020 … you look at our ancestors, not that long ago, pre-Industrial Age, the early 1900s … our skulls don't look the same. Our airways are shrinking. How many people do you know who’ve had their wisdom teeth out? It's almost everybody; who hasn't had their wisdom teeth out nowadays? Our great grandparents didn't get their wisdom teeth out — not because they didn't have the medicine to do it, but because their jaws were bigger, their airways were bigger.
Lauren: Why do you think that is? It seems like a fault in our biology, doesn’t it.
Dr. Kandula: It seems kind of strange. But similar and actually related, I think, to the allergy thing that you just said … allergies are so common these days.
Lauren: Well, that’s environmental, for sure.
Dr. Kandula: It is environmental. So if you walk it back to the Industrial Revolution, things have changed in our environment, there's different things in the air. Additionally, our environment at this point … its going to sound weird … but it's so clean and so managed, that we're not exposed, our bodies aren't exposed to the things that our ancestors were. So back in the day, simple things … like, if you were living in a farming community, you were breathing in stuff constantly from when you're born. And your body sort of adapts to it and says, hey, that's pollen and no big deal … we're going to move on. Now in our new environment, you're walking around in a city, you're walking around with your hands nicely washed, everything's clean — and all of a sudden, you see a little bit of pollen come through. What allergies are … your body’s misidentifying something as an enemy. So your body's breathing a little pollen in and saying, that's a poison and we’re just going to shut that down. We're gonna shut that down by swelling the lining of your nose up, making your eyes itch and water, your nose run, we're gonna make you sneeze. And so it's taking something that's not a problem and making it a problem. But your nose is the start of your airway. So if your nose is a little bit stuffy, and you’re a child, then what ends up happening is that a nose that’s stuffy causes your mouth to drop open — maybe just at night, maybe day and night. A mouth that's open creates a domino effect there, too, where your jaws do not form properly. You can make a nice story that way; not everybody who has sleep apnea has that story. But a lot of folks do. Most folks with sleep apnea, the issues actually started way back in the day — a lot of times when they were kids. And they might not have had sleep apnea then, but they were sort of destined, or programmed, because of their environment, to have an airway that they weren't supposed to have. And then as you get older, and your airway is compromised, most people, I think … when you hear the words “sleep apnea”, a lot of folks think, oh, you have sleep apnea because you’ve got too much weight on. And sometimes that's true. But I'd say the flip opposite is actually more true. And this is something I've recognized more recently … unfortunately, if you have a compromised airway, almost a guarantee is you're going to have more weight on your body than you're supposed to have.
Because it's hard to be active and productive and make the right choices food-wise when you're not breathing and sleeping properly.
If I don't get a good night's sleep, the next day, I'm less likely to exercise and more likely to eat trash. And so if you eat trash and you’re out mobile, then you're going to put some weight on. If you’ve got weight on and you have a compromised airway, that's going to make your airway even tighter … there you go.
Lauren: It’s a vicious cycle. Do you think it's something that perhaps more people should be getting tested for? Sort of as a baseline. We go in for our annual checkup at our GP; should we be having our airways checked as well?
Dr. Kandula: It’s a slippery slope there. I think yes if the person who's looking and thinking isn’t just checking a box off. Because unfortunately in medicine, as anybody who goes in and interacts with the healthcare system these days, there's a lot of box-checking and not a whole lot of listening and not a whole lot of common sense going on these days. But yes, I think if we had a system in place where somebody who has a question or thinks … man, maybe I have this issue, I'm not sure … if those people could go in. The way we diagnose this is so simple these days; it's an in-home sleep study. So you don't have to go to a sleep lab. You can sleep in your own bed. It's a simple device. You go to sleep with it one night; you bring it back, we download the information and it tells us exactly what's happening. That's a big deal. That we've been able to do really well for the last 10 years or so. Prior to that, everybody had to go into the sleep lab. Sleep labs still have their place in the world today. But a small place. Anyway, I'd say, awareness of these issues, diagnosis — and going from there. When you think about healthcare in general … I actually try not to.
I try to think about the person who's sitting in front of me. That's the most important person in the world to us.
When you do that, when you're actually intentional and in the moment, that’s, I think, how you actually change the world. But if I allow myself to fly out into space and look down upon us, I'd say if you think about healthcare in this world and in this country specifically, a massive change that could be created in a simple manner would be to diagnose all those folks out there who have sleep apnea and to treat them properly. Because of all the other things we talked about. When you look at healthcare spend and you look at heart attacks, and strokes, and diabetes, and depression … I could go on and on and on … if you could magically wave your wand and take those things out of people's lives, that’s massive impact on lives. But it's also massively decrease spend from just a global standpoint. So it's a win-win. But the challenge is, that people have a hard time connecting those dots — which again, is why I like to talk about some of these things. Because some of it gets a little complex, but a lot of it, I think, is very, very …
Lauren: Deceptively simple, isn’t it.
Dr. Kandula: It's very simple. It’s literally in front of your face —that’s where the answer is!
Lauren: Literally, that’s the place where it all happens!
Dr. Kandula: That’s it. There's not many things where it’s right in front of you. It’s right there.
Lauren: It’s very interesting, because it seems to me that you're actually, in your practice, taking kind of a root cause approach. Which is a more functional medicine ideal. But actually, in my discussions with various practitioners who I've had on the show, it seems to me that the agreement tends to be among doctors, and especially good ones, that we should be taking an integrative approach in all medicine, shouldn't we.
Dr. Kandula: Correct. The challenge is that the system isn't built for that. So if you try to do that, you're bucking the system. And it's hard to buck the system. Most people don't want to buck the system. And sometimes when you buck the system, the system bucks back.
Lauren: I’d say that's more often than not.
Dr. Kandula: It's not for the faint of heart, and most people are faint of heart. It’s kind of what I was saying before … I was a good boy for a while, and then what I began to understand is that, being a good boy and playing by the rules of a system that's broken, morally I'm not okay with that. We are sort of as buttoned-up as you can be.
But all I'm saying is that if you believe there's a problem and you believe you have a solution, then it's your duty to to bring that full force.
And that's all we're trying to do. And back to … yes, I would say, the integration of some of these disparate areas in healthcare would be wonderful. But the solution for that will never be a top-down approach. It cannot happen. Because when you go top-down, you crush what's on the bottom. It has to be a bottom-up approach. And when you're on the bottom, you try to raise awareness and bring things up. Again, you're fighting that entire system that's above you. And so yes, we need more people who are willing to fight the good fight.
Lauren: I couldn't agree with you more. I'm sure our listeners would agree as well. So I'm wondering, in terms of the people who come into your practice, are you finding that you're dealing with hypochondria at all in the practice? This is always my question, particularly as it revolves around invisible illness. The number of us who've been told that we were fine when we weren't. Obviously, you talked about patients who are coming to you and are frustrated by the time they get there because they've dealt with not being believed. But by the time they get to you, are you seeing any hypochondria in your practice? And how do you handle it if you do see it?
Dr. Kandula: Honestly, I wouldn't necessarily say I see so much hypochondria. I'm trying to really think about it … the definition of hypochondria to me means somebody who doesn't have an illness and thinks they do, or wants to. I don't know, one of those two things. I do think there are some folks who come to see us because they do think there's something wrong with them. And sometimes they just want us to assure them that things are looking okay. The truth there, though, is that many times — not all the time, many times — as people sort of wonder, I think there's something not quite right, and we dive beneath the surface and we look, many times we actually find that that's true. In fact, I see a lot of people who maybe have been pegged as something like that (hypochondria). And actually they had an issue. I'm thinking about this honestly, but to me, the greatest sin that we could do is as clinicians is to dismiss somebody because of our own ignorance or inadequacy,
Lauren: Or ego, maybe.
Dr. Kandula: And sometimes … it's sounds harsh … but I think sometimes it's intentional — meaning that "you're taking a lot of time out of my schedule, and I don't have the time for you today, buddy.” You know, that's intentional. But I think a lot of times, it's a lack of understanding. And even some of these airway things we were just talking about … that if you don't understand that concept, if you don't understand that a narrow airway can lead to sleep apnea … and sleep apnea can lead to depression, for instance. Again, those are simple jumps to make. That's absolutely been proven.
If you're seeing somebody for depression and you don't open your mind and start trying to walk your way back to the root cause, then you're not doing that patient a service.
And I think especially for mental illness specifically. I don't want to necessarily open up that that door, but there's so little good science there, in my opinion, and so much chatter and disinformation.
Lauren: It actually sounds like, from your perspective, a lot of mental health issues actually have a physical beginning, and it's not like a brain issue necessarily, but more to do with the rest of your anatomy.
Dr. Kandula: Potentially. Certainly there are people who are depressed and have no airway issues whatsoever. And that's a shame, and they ought to be treated. But again, my bias is a bigger shame … let's just use this as example, somebody who's got depression and actually has an airway issue and actually has sleep apnea that hasn't been treated. That's not a shame, that's a sin. And it's not just sad. If you think, good God, if we would have just had our eyes open, understood the situation, treated that medical/physical issue … that might have prevented that whole other issue. That goes back to the awareness; that shouldn't happen. And if I have anything to do with it, under my watch, it won't happen. Now, it still does happen — because I'm one person and there's only so much I can do. But I would say that if more people had awareness and the attitude, to just check it out. If you or somebody you loved had this issue, and you could simply figure out what's going on, why wouldn't you do that? You should do that. And anybody who says otherwise, I need to hear a counter argument to that.
Lauren: To make sense of it. You've touched on doctors who are strapped for time, and how the system is kind of rigged against not only doctors but patients in that way as well. I wonder, how have you found in your practice a way to work around it? Have you removed yourself from the larger system of health insurance entirely in order to deal with that?
Dr. Kandula: We haven’t. We walk this fine line … and I'm sure this is not the first time you've heard this … people have their health care insurance and they would like to use their healthcare insurance.
Lauren: Well, because they still need it to be affordable.
Dr. Kandula: Sure, and we understand that. For us, it’s, like, okay, how do we help our patients if we can play by the rules of the system…
Lauren: Just enough!
Dr. Kandula: But yeah, kind of. It’s a truth that exists today … people who have health insurance want to use it for their health care. Okay, fine. Now, the rest of the system … A typical medical practice, a typical ENT practice, if you're going to go see an ENT, you're going to go see the doctor the first visit and every visit. And that's a good thing. That’s a fine thing. We don't do that here. And that sounds kind of weird, but, how we approach our patients … we call it team-based care. So we have PAs and nurse practitioners and MDs — and we work together. By doing that, it allows us … for instance, if somebody comes in to see us, their first visit is going to be with a physician’s assistant or nurse practitioner. Now, some people might not like that, and those that don't like it don't like it because they don't understand why that’s set up that way. If somebody is willing to listen, I'd say, “Hey, I get it. I understand that you want the best care that you can have. The reality is, this is the best way to do that.” Because when we do it that way, that physician’s assistant, at that first visit, has plenty of time to sit down, look at you, in the eyes, talk to you like a human being and understand what's going on. And then use the tools that they have to look at you. And again, let's say it's an airway issue, to look at what's going on anatomically and say, “Okay, I hear what's going on; I can see what I see here.” And then if additional testing is necessary, say a home sleep study’s necessary, or imaging is necessary to look at the nose and the sinuses, they're going to get those things set up. And then the next time that you're going to come in, now you're going to see the doctor who now has the information that they need. Now they have the time.
So instead of wasting that doctor's time by doing information gathering on the front end, let's make sure the doc has all the information that they need.
So when they sit down with you, we're not wasting your time or their time — and that's how we do it. So really what we do is protect and preserve our doctors’ time by making sure that our docs are doing things that only doctors should be doing, and we protect and preserve our PA’s time that way. And that works OK within the system.
Lauren: It sounds to me like it's more of a medical concierge system. So many patients struggle when we sit down with a new doctor to tell the story, right? There’s so much that can get lost in translation. It sounds like you're bridging that gap by bringing the PAs or the nurse practitioners in first to create the story in the doctor’s language, so that there is an understanding between doctor and patient, and you can lead them through the process. To me, it's more sensible and it's a shame that more practitioners probably haven't figured that out yet.
Dr. Kandula: Right. And there’s a counter argument to that. As you said, and I kind of repeated, is … we don't have the perfect system and our system, we're always working to make it better. But our system is as good as we can make it to be in the day and age that we live in. Meeting all of our masters. We serve our patients. But in order to serve our patients, we need to work with their insurance companies, because that's what most people want. We thought and talked about, well, could we just buck the whole system? We could, but then we would actually reach fewer people and fewer patients. That's not a great option for us, what we're trying to do. So yeah, it's trying to say, “Okay, these are the rules. With these rules, how can we continue, or how can we deliver the best care that we can?” And in this day and age, this is how we do it. And it really does work. I'm a better physician because I work in the system that I work in than I was, back 10 years ago, when I was seeing every patient every visit, and there was just so much time in a day. In addition, there's also so much time that somebody can be truly present and engaged. And I think the frustration on both sides, from a physician and a patient standpoint, is when a patient comes in and expects full engagement, full attention — and doesn't get that.
And then as a doctor, if I were put in a situation where I was not able to be present and fully engaged, I would feel like I’m compromised.
Most doctors in this country, they call it burnout. But they're getting crushed in the system as well, because they aren't able to do what they got into this business to do, because the system is so discombobulated that it just ruins it for everybody. It ruins it for the patient, it ruins it for the physician. And then everybody's unhappy … which is a shame, because doctors are, generally, in it for the right reasons and want to do the right thing. And the system sort of almost makes it impossible.
Lauren: Yeah. Well, is there a special training that practitioners in your practice go through in order to address that patient feeling of frustration? That so many patients are coming to you after going through doctor after doctor after doctor, getting no answers maybe, or getting the wrong answers, and feeling very frustrated and like they've been shuttled from specialist to specialist. Does that mean that you're also making sure that the clinicians who work in your practice are practicing greater empathy toward patients as well, that their bedside manner is a really important part of the hiring process?
Dr. Kandula: Yeah, yeah. Basically, anything short of excellence in that regard is a non-starter. Part of it is, if you're in a culture where that's the expectation, then you raise your game if your game wasn't there to begin with. We don't actually sit and talk about this so much; we do. We model by doing, and that's the culture that we have. We've got a few core values. The first is called Advent’s Golden Rule. The Golden Rule is: Do unto others as you would have others do unto you. Advent’s Golden Rule, is not just doing as you would have others do unto you … also doing the ideal thing for that person. Sometimes, and especially in this culture and this day and age, I think a lot of people don't do or think enough for themselves. Meaning that a lot of people expect or accept a compromise life and a compromised situation. So if you just follow The Golden Rule, you actually aren't treating somebody the way that they ought to be treated, in my opinion. So here, it's really more a matter of optimizing the care of that patient by caring for that patient. These are all words and words are cheap, but action is where it comes into being.
Lauren: It's making the patient number one, and doing good by them.
Dr. Kandula: Absolutely.
Lauren: We've talked a lot about the ways in which the healthcare system is rigged against doctor and patient. I'm wondering if there are ways in which you see it working in its current form?
Here's what I'd say … In this country, in my opinion, when all cylinders are firing, we have the best health care in the world. But what I said before … the system is broken.
There's so many barriers to entry towards getting it to where it’s firing on all cylinders. The system works better than anywhere else in the world, but then how do you define that? That's where you start losing it. Because we've got millions of people in this country … is it averaging the care for all those people, every individual …
Lauren: Yeah, if you look at access, we're not doing so great.
Dr. Kandula: Correct. But if I guess that's the thing … if you have access, and you have an issue, and you get plugged into the right resource,
you're going to get the best care around. And in the world. What's my proof of that? Because in may specialty, folks come from around the world to hear about what we can do here at that top level of care.
Lauren: It’s not all terrible.
Dr. Kandula: It’s not all terrible. There are great, great things happening in healthcare.
Lauren: How do we increase that access, though? If the patients who are getting care are getting a very high level care, how do you as a clinician, how do I as an advocate, how do patients … create better access so that our success rate can keep going up?
Dr. Kandula: That’s a tricky question!
Lauren: That’s the one we're trying to figure out!
Dr. Kandula: I guess I'd say that would start, if you're a healthcare consumer, having an expectation and also a will or a say in the game to begin with.
And when you aren't receiving the kind of care that you feel like you expect, letting it be known.
Lauren: I think it's a philosophical discussion as much as it is a logistical one.
Dr. Kandula: It is. But I would say if people who become patients are empowered …
Lauren: Well, we're all going to become patients at some point. That’s something to keep in mind, right? We’re all going to need the system at some point.
Dr. Kandula: Absolutely. When you cross that door into a health care facility, you are in charge of your care. And if you have that mindset, then you're going to watch out for yourself and protect yourself and make sure you're getting what you need. It’s a different mindset. Both my parents are physicians, and I remember when I was a kid, there was much more of a paternalistic model. And it still exists. I think you have this overlap of a paternalistic model, which means you go to the doctor and the doctor is like your parent.
Lauren: And you do what the doctor says.
Dr. Kandula: You have vestiges of that. There was a time and place where maybe that existed. In the current day and age, there's a memory of that, but then a system that doesn't at all behave like that.
And then we're also in an entirely new information age, where literally every single person walking around this world has access to as much information as their doctor does.
Lauren: Well, and that's great because you're even participating in that information system, right? You're posting videos that have information about your practice and the kinds of patients that you're seeing, and tests you're running. So being aware of looking for that kind of information from a patient perspective.
Dr. Kandula: Yeah, it's good, and if somebody is motivated, you can find a lot of stuff. Sometimes it's too much stuff.
Lauren: Well, and how do you know what's real and what's not? Because we're in this post-truth world.
Dr. Kandula: Exactly. And that's the challenge. So we moved from a paternalistic model to your physician being kind of the arbiter, I think, of maybe truth versus non-truth to some extent. It's a different role that you're serving. When my parents went through medical medical school, you could only get this information by going through medical school, and that was it. And if you didn't go through medical school, then you’d need to just listen to what we're saying. Nowadays, everybody's got access, but then nobody knows what to do with all that information.
Lauren: Right. So it's the other end of the same problem.
Dr. Kandula: Correct. And at least in my lifetime, that’s happened. And then that's where you get a system where you get so much frustration, I think, because you have some disconnects there.
Lauren: So, when patients are coming to you and saying they have sort of a nebulous symptom situation … oh, I'm kind of tired … my nose is a little stuffed … what kinds of tests are you going to run on patients when they first come to your practice?
Dr. Kandula: First is listening. First we need to understand what are you noticing, and sometimes that's crucial.
It's crucial for us to hear you, but then it's also crucial for us to maybe hear between the lines of what you're saying.
And then based on that, we actually look. Before we do any sort of additional testing, it's looking at you. Fortunately as a head/neck doc, this is easy access. We can look in your nose, we can look in your throat, we can see everything we need to see.
Lauren: You’ve got all the scopes.
Dr. Kandula: Exactly. So you don't even have to undress to see us, so it's nice. And then really, between what you say and what we’re seeing, we pretty much have a good sense as to how likely are you to have, let's say, sleep apnea. The first time you come in, we should have a pretty good guesstimate. And if we say, it seems from what you're saying and what we see you're likely to have this, then absolutely, we'll do a home sleep study to see what's going on. And then we’ll go from there. It’s taking the tools that we have, and making sure we use them in the right way. And the same thing from the nose and sinus standpoint, common tests that we would do would be imaging of the nose and sinuses. Because we can't see into the sinuses when we look at you; we have to use X-rays to do that. So we do that when necessary so we can see what's happening behind the scenes to know what's going on so we can treat you properly.
Lauren: So with someone like me — I’ve got a C-pap. Do you see that as a long-term solution to something like sleep apnea? Or is it imperfect. Because I often say to myself, gee, it's a good thing my C-pap is more compact. They’ve gotten smaller over the years, but it still feels like a bit of an ancient way to be treating something … that we haven't come up with something more convenient, if you will.
Dr. Kandula: It could be a permanent solution. It is a bit of a …
Lauren: A gray area?
Dr. Kandula: Well, I wouldn't say it’s so gray. If you have sleep apnea, you have three options: You have C-pap, you have the oral appliance option, you have surgery. Most people who do well with the C-pap machine would do just as well with an oral appliance, but most people who have sleep apnea have never heard about the oral appliances. And to me, that's not right. And nobody is going to do very well if their nose isn't working. If you have sleep apnea, like I said, you have a throat issue. There’s about a 70, 80, 90% chance your nose isn’t optimal either. And so if you're in a C-pap machine, the best way for the machine to work is: mouth shut, nose open just in a nasal mask. If you're in an oral appliance … appliance in your mouth, nose open, you know that's working. And even if we do surgery on your throat, same thing … your nose needs to be working. So to answer your question, I'd say it's a good solution.
It's really the gold standard that we have right now.
There are advancements on the surgical side of things. The tools we have there … I don't want to go into too much detail, but I'd say if somebody has sleep apnea and is using an oral appliance, what they’re doing is putting something in their mouth that's pulling the lower jaw forward. Your tongue is attached to your lower jaw and that opens up the back of your throat when you just move that a few millimeters. There are ways to actually change the configuration of your jaw through massive surgery. There's a standard surgery out there now … and you probably have not heard of this … but there's a big-time surgery where they break your upper and lower jaws.
Lauren: Oh, I've heard of this! And I’ve thought, oh God, I hope I don't end up having to have my jaw broken. I like my jaw!
Dr. Kandula: (laughs) So there’s this big bad surgery that actually works really well, but nobody really wants to go down that road — unless they have a really good reason to go down the road. Now if we had a more elegant approach to do a similar sort of thing, I think a lot of people would go down that road. There are those options, and I don't want to get into a whole lot of detail. But if you had a lower-key procedure, and changed your airway, a lot of people would move that way. But really right now, in this day and age, I think most people are better served .… actually, honestly, I think most people would be best served in an oral appliance. But you have to work with a dentist who knows what they're doing and wants to be able to work with you. Most people who come in with sleep apnea or are questioning sleep apnea are pulled into a system that's rigged.
Lauren: You’re going to have to try the C-pap first. It’s like a fail-first situation.
Dr. Kandula: This is the only option and it's this or the highway, buddy. I think a lot of people get that, and there's never a discussion about any other option. But anyway, back to the machine … I'd say yes, it's nice that the machines are smaller and quieter and better than they had been back in the day. It'd be nice, if you had sleep apnea, if you didn't have to have a machine to begin with.
Lauren: I often think that when I travel and I have to carry this extra briefcase around with me, and I think this would be so much easier if I didn't have to. I’d love to be low-maintenance again!
Dr. Kandula: Absolutely. Have you heard of that oral appliance option?
Lauren: I tried it actually, I did the C-pap first, and was only offered a mask that went over my nose and mouth. No one told me about other masks. That didn't work because it kept me up all night because the chord hit me in the face every time I moved. So then I tried the oral appliance, and went through months and months … I kept getting infections in the corner of my mouth, the appliance wasn't fitting right. We kept adjusting it and ultimately, it just didn't seem to work. And then, I found a new sleep doctor and explained what had happened. He was, like, “Oh, why don't we just try a different mask?” And he got me the nose pillows. And it's been like night and day. I still find it's not a perfect solution because it's not something that is fixed. It doesn't mean that your mouth won't open, it doesn't mean that you're not going to move and it might go off-center a little. So it's still not perfect. And I do wonder … and this is exactly why I went to my GP and said, “Hey, I think I might have some kind of underlying issue that might require a more elegant surgical option.” And I said, “Look, the C-pap’s fine, but I actually think what's happening is that I'm having a sinus issue and I need to get it checked out.” So there could be all of these underlying issues. I could have gone on with the C-pap for another 60 years. But maybe there's an easier option.
Dr. Kandula: Correct.
And I would say that our system is built with the assumption that most people would rather not use a machine unless they have to use a machine.
So our bias is that way, versus the opposite. Now, we certainly prescribe a lot of C-paps, and a lot of our patients are in C-paps. But the system is built that way. The other part of our system is we start with a nose; it's a nose-first approach, because your airway starts with the nose.
Lauren: See, no one's looked at my nose.
Dr. Kandula: Right. Now the reality is that your sleep apnea is not coming from your nose, period. It's coming from your throat. But some of what you just said … and you're not alone here … your story is every person's story … it’s the system of jumping to conclusions and jumping to treatments before we say, okay, we can jump but let's walk logically in a forward direction. How we do things here is, listen to you, look at you, if we think there's something going on nose- and sinus-wise, we're going to make a pit stop there before we go too far down the road. Now if we look there … either we look and everything's good and we're gonna let you know about that … or we’re looking and it’s not quite right, we’re going to talk through what's not right and what might we want to do about that. Before we even get you into any active treatments for sleep apnea. We would overlap that step and say, we need to just do a sleep study. But before we get to any active sleep apnea treatments, we are either going to give you the stamp of approval for your nose, because your nose is good and your sinus is good by themselves, or we're going to do something to make them optimal or better or reliable. Before we even put you into a C-pap machine or an oral appliance or anything else. The number one reason for people to not succeed with a C-pap machine is because the nose is blocked up and they don't know about it. The number one reason for somebody to not succeed with an oral appliance is because the nose is blocked up and they don't know about it. And so for you, I don't know; your nose might be just fine. But I'd say it makes me wonder … folks whose noses are working properly and are in an oral appliance that's well fitted for them, they tend to do really well. Not everybody. Certainly there are exceptions to that.
But the rule is, nose working, appropriate appliance — oral appliance — people do well.
And I’d actually say a similar thing with a C-pap machine. If somebody has nose working … then we put them in a C-pap machine … and ideally within days … Again, the reason you got put in a full-face mask is, that's just the laziness of the broken system which says … You have sleep apnea. We don't really care about you. We're going to shove something on you. We don't care about the fact that most people cannot tolerate a full-face mask, because it's really claustrophobic.
Lauren: Oh, yeah, that was the other thing. I felt really claustrophobic.
And I had never experienced claustrophobia in my life.
Dr. Kandula: And it's frightening.
Lauren: And I couldn't get to sleep because I was anxious. That was setting off my fight-or-flight, right. But I imagine that the apnea itself, the the fact that I would stop breathing in my sleep, surely that's setting off your body's fight-or-flight response every time it happens. And it could happen, upwards of 15 or more times an hour. So the fact that it can happen that often in your sleep. We talk about dealing with chronic stress in your waking life. Imagine if you're having it in your sleeping life, too. And this is exactly why sleep apnea is such a dangerous issue to deal with, and why you need to get it treated if you have it.
Dr. Kandula: To me, there’s many definitions of insanity. But as you just said, if you kind of follow the ball there … if you have sleep apnea, it’s a throat issue, and again, you're likely to have a nose issue. So your throat is tight, your nose is tight. How can we truly ruin this person's life? We're going to put something over their tight nose and tight mouth. And somehow think that they're gonna go to sleep with that. It just doesn't make any sense at all. And yet, that's the standard of care. And absolutely … that fight-or-flight reflex … if somebody has sleep apnea, multiple times, sometimes more than 100 times every hour, the body's shutting down, the body is just revved up. And it knows your airway is not working right. And it doesn't trust the airway. Now all of a sudden, like I said, somebody's going to shove this thing on you. That's why the compliance rates are so poor with C-pap; it's an insane process and it's the standard of care. Your story is the story I hear all the time. Again, maybe that's just how it is …
Lauren: But here we are, three years later, too.
Dr. Kandula: And a lot of folks jump off of that journey really early.
A lot of folks go in, do a sleep study, get the C-pap machine, can't tolerate it.
I’d say there's one thing between “I can't tolerate this, I can't do this” versus “This thing, it feels like it's going to kill me.” And then you go to tell your doctor, "I tried this thing, and I felt panicky, I felt like I had claustrophobia.” And what your doctor’s going to say is, “Well, try it again.” And you’re, like, “See you buddy, I'm out of here!” And that's what you should say. You should say, “I'm gone. That's crazy.” And your mind is saying, don't do that.
Lauren: And why haven't health insurance companies then responded to the fact that there's such a low rate of response the first time around with the C-pap! They should be addressing other issues.
Dr. Kandula: Absolutely. Because they really don't get it. We've had many recent interactions where I'm talking to insurance companies, and they have no clue, unfortunately. The insurance companies, it's easy to bash them. But I'd say, the truth about all insurance companies is they absolutely are focused on their bottom line. And even there, if they actually listened to some of what we're talking about, if you're a bottom line guy or gal, this is bottom line. If we can treat these issues early on and prevent these downstream complications … if you're a top line, bottom line, or just sort of going-the-rule person, it hits it right there. It’s good, it’s good in all regards. But they don't actually listen. In fact, I think how they're wired is, they would rather not see that you're diagnosed with sleep apnea, because that means you're going to get some treatment and they'd rather not have a treatment …
Lauren: Because, they get to deny you anyway.
Dr. Kandula: Which is insanity. Even if they were truly looking out for their own selves, and they understood the dynamics, they would want you to get treated — because it actually would end up saving them money in the long term.
Lauren: And I'm wondering, because we're talking about success and failure rates with something like C-pap, when you see a new patient, and maybe you found the solution for them … maybe it’s a C-pap, maybe it's an oral appliance, maybe it's someone who's going for the surgical option … how disciplined do patients needs to be when it comes to these changes in their lifestyle? Does the diagnosis mean that they need to upend their lives and make it happen all the time. Like, just because I have a C-pap does that mean I have to use it every night or I'm going to get a heart attack?
Dr. Kandula: The short answer’s no. Part of it depends on the severity of your sleep apnea to some extent, but one night away from the machine is not going to do you in. But multiple nights … it's the damage over time that gets you from sleep apnea. Though, most people who have sleep apnea and are being successfully treated, don't want to go a night or two without their machine or appliance, because …
Lauren: Because you’re a basket case the next day.
Dr. Kandula: Exactly. That's where the world sort of lets you know how bad the problem was. We see this all the time for a variety of things, including sleep apnea … once you get somebody treated properly, and you get them back in the normal realm of existence, and then one night away from your machine all of a sudden sucks you back into the life that you used to have — and it's no longer acceptable to you.
Because now you have this new understanding, new life, new awareness.
If we're treating somebody successfully, we don't usually have to do much arm twisting. Because if we're truly successful, then our patient is on board with that treatment. If the treatment is working, they want to use it because it's working for them. Versus, “Hey, buddy, you’ve got to use this or you’re going to die.” That's not a really convincing approach. Scare tactics don't generally have a place here.
Lauren: Not fear factor, care factor. Care over fear.
Dr. Kandula: Correct!
Lauren: So I like to wrap up my interviews with a Top Three list, and for practitioners who I have on the show, I'm wondering for you what would your top three tips be for someone who maybe suspects they have something off? Maybe they're about to become a patient of an otolaryngologist, ENT. They might be living with something invisible, that's chronic. What would you recommend to these people who are on the precipice of diagnosis?
Dr. Kandula: It’s a good question. I think the first thing is establishing an awareness of what it might be. We’ve kind of focused on sleep apnea in this discussion, and that’s just fine. But if it's sleep apnea, do a little homework. You don't have to do a ton of homework. Just get an understanding about, what does sleep apnea look like? Might this be you? Might this not be you? Okay, if this is you, if this is a possibility, then the next thing is: Do your next bit of homework and find the right resource for you. It's tricky. I know what I do, and I know what we do here, but we are in Milwaukee and Chicago, and we're not in California. Not that we're the be-all end-all, but it's finding the right resource from a medical standpoint. Okay, I think I have this issue. These folks seem like they know what they're talking about. That’s step one. Step two, step three is: Once you find the right resource … or resources, maybe it's a couple of things … trust your gut and trust your head: Does this seem to be making sense to me? And a way for you to easily check that is, when you're going into your clinical appointment with your MD, PA, whoever … do you have confidence that they understand what's going on? Do you understand; if they understand what's going on, have they explained it properly to you so that you understand it? And then I'd say the final thing is:
Do they have a specific game plan designed for you moving in a forward direction? Meaning, when you go in, do they listen to you?
Do they understand you? Did they evaluate you in your mind properly? You don't have to be a doctor to figure this out, but have they really heard you and and looked at you?
Lauren: And given you a roadmap.
Dr. Kandula: Yeah. I don't visit doctors often.
Lauren: That’s interesting. A doctor who doesn't visit doctors often!
Dr. Kandula: Yeah, and when I do go, I always am shocked at the lack of all the things I just said. I'm a doctor so you can speed through the process. Cut to the chase.
Lauren: Yeah, use the language.
Dr. Kandula: Use the lingo. Tell me what you think is going on. You don’t have to do the explanation part so much, but just say, “I think it's X, Y, and Z, and we're going to do this and that — and boom, done.” It doesn't happen. When I go in, or if I'm taking my kids in, or I go in with my wife's appointments, it's always like, this is craziness. Not that I impose my will on them, because I'm not gonna tell them how to practice medicine. But I always leave, unfortunately, shaking my head. I shake my head because I get a first-hand experience of what the experience is for most people out there. And it's not okay. And so I'd say, back to the 1, 2, 3 is: Educate yourself. Make sure you feel confident in the resources that you're reaching out to. And then finally, I'd say, make sure you're getting results. And results that are delivered by options.
If you have an issue, make sure you are getting all the options that are there, including the options that this particular person can't deliver for you.
They should understand the things that they can and can't do. Now it's back on you, man. Now it's on you to take that information, synthesize it, and then make the choice that's right for you.
Lauren: Making an educated decision.
Dr. Kandula: Absolutely. And unfortunately …
Lauren: Well, it’s become the patient's responsibility when the system’s failing us. Is there anything else you'd like to add? Certainly, please, tell listeners where they can find you and your practice.
Lauren: Oh, it’s both? That’s so funny!
Dr. Kandula: Either way. It’s either hokey, or memorable, or one of those things!
Lauren: Well, at least you've got a sense of humor about it all!
Dr. Kandula: We do. But that's where you can find us, and as you said, there's a lot of videos and information. Because we are out and about on the Internet, we get folks calling in from all over the place. And sometimes it’s: “Do you know somebody in Sacramento?” And maybe I don't, but maybe I do, and if we do we try and hook you up. We do get folks coming in from far away for treatments, which is cool in a way but uncool in that they have to do that. Part of our mission here is, we have what we have and there is a need for what we're doing. And we are trying to grow this as quickly as is feasible, because we have to maintain the quality that exists here. So ideally, eventually we would like to be out where you're at, because it's hard. It's hard for folks to try to come in to see us. But anyway, it's easy to find us online and hopefully we can get you some more information if you visit us.
Lauren: Well, when you end up in California. I'll be your first patient!
Dr. Kandula, thank you so much for joining us today. It was such a pleasure chatting with you.
Dr.Kandula: Thank you!