New Book: THE CHRONIC COUGH ENIGMA (“Integrated Aerodigestive Medicine” Excerpted)





Any person with an enigmatic chronic cough will tell you that the specialist model of American medicine has failed. In truth, it has failed for a large number of patients and at many different levels. Not only do we have too many specialists, but too many practice so narrow a specialty that often patients receive incorrect, expensive and wasteful medical care.

An illustration of the chronic cough patient’s predicament with the specialist model of American medicine is the elephant in the fable of the three blind men and the elephant:

The first blind man, feeling the leg of the elephant, exclaims, “I can see it clearly; the elephant is like a big tree.” The second blind man holds the trunk and says, “No, the elephant is like a very large snake.” The third blind man grasps an ear. “You are both wrong,” he proclaims, “The elephant is really like a gigantic leaf.” Each blind man embraces a part of the truth, but none understands its entirety.

In the case of chronic cough, the three blind men are the three medical specialties: (1) the otolaryngologist (ENT, the ear, nose, and throat physician); (2) the gastroenterologist (GI physician); and (3) the pulmonologist (PUL, chest and lung specialist).

The problem is not just ignorance. Today, many doctors behave more like entrepreneurs than healers. Each “profit center” attempts to maximize income by manipulating the medical billing and coding system. Indeed, most medical professional societies offer their physicians advanced training in coding so that they can effectively maximize income.

It is worse than you think. Today in most hospitals, coding specialists routinely make patient-care rounds with the doctors to insure that no code goes unbilled. The idea is that hospitals want to absolutely maximize possible income. And yes, they stretch the truth a lot every day to do so.

Conflicts of Interest and Corruption Are Why Healthcare Is So Expensive

The needs of patients have been lost in a healthcare system dominated by for-profit corporate medicine characterized by conflicts of interest, price fixing, and corruption.

In 2012, I had back surgery, a L3-L4-L5 fusion. I now have two titanium plates and six screws in my back. The hospital billed $111,000 for the hardware alone; unbelievably, it actually was $15,000 per screw. (I know for a fact that you can purchase an excellent quality titanium screw at Home Depot for under a dollar.)

The punch line is not that hospital billed so outrageously, but that my insurance company (United) paid them $146,000 for my surgery ($99,000 for the hardware) and that didn’t cover professional fees. My surgeon charged $117,000, and I believe that he received $104,000. Meanwhile, I am still being billed by the hospital and the surgeon; both want more money.

The total bill for the surgery was $260,000. In Sweden comparable surgery costs about $10,000. One might reasonably ask where the other $250,000 went.

Returning to chronic cough and reflux, there is corruption in endoscopy. Many doctors have profound conflicts of interest because of ambulatory surgery centers. ASCs are big business. Typically, a doctor negotiates an ownership position in an ASC with the understanding that s/he will perform a certain number of procedures, say 1,000 per year, at that ASC. Conflict of interest?  The return on investment is astonishing!  One GI from New York happily informed me that his annual income from his ASC was $800,000.

Last year, there were 10 million sedated endoscopies performed in the U.S. at a facilities fee cost of $10 billion, that is, an average of $1,000 per procedure. And that does not include the professional fees of the gastroenterologist, anesthesiologist, and pathologist.

Also questionable, when GIs perform upper endoscopy for reflux, they routinely examine the entire upper GI tract and perform biopsies. Why? Is it because EGD (esophagogastroduodenoscopy) with biopsy pays much more than a lesser procedure or a procedure without biopsies?

When it comes to non-pulmonary chronic cough, pulmonologists also appear to be inefficient and wasteful. When a patient comes to a pulmonologist with any type of reactive airway disease or shortness of breath, the doctor will usually perform pulmonary function tests (PFTs). S/he may also perform bronchoscopy, endoscopy of the airway and lungs, but these doctors are not trained to examine the throat. When it comes to silent airway reflux, the usual result is misdiagnosis and incorrect treatment.

Most pulmonologists diagnose asthma in all cases of reactive airways disease, because they apparently cannot differentiate inspiratory, airway reflux-caused reactive airway disease from true asthma characterized by expiratory wheezing. The misdiagnosis of asthma is costly. No one knows exactly how much; however, asthma medication costs $56 billion annually in the U.S. See Chapter 7: Asthma that Isn’t Asthma.

Otolaryngologists should be able to examine the larynx (voice box) and throat, but they are generally handicapped by outmoded instrumentation and inadequate training. Thus, most ENTs can neither accurately diagnose nor effectively treat airway reflux.

Perhaps the greatest waste due to inaccurate diagnosis in the otolaryngology area is sinusitis. Many patients come to me after having had multiple unsuccessful sinus surgeries, still suffering the same symptoms. Yes, again it’s airway reflux. Nocturnal (nighttime) reflux in particular can cause sinus symptoms, the most common of which is post-nasal drip.

The typical chronic cough patient who comes to see me has been coughing for more than a decade and has already seen more than a dozen physicians (ENTs, GIs, PULs, allergists, etc.).  One patient who had been coughing for 20 years reported that he had seen 34 doctors, some from four major medical centers, before seeing me.

Restructuring Healthcare

Where did this excessive, inefficient, and unnecessarily expensive medical mess come from? The healthcare industry has shown a strong propensity to chase funding. When Medicare agreed to cover renal dialysis, for example, thousarnds of new dialysis centers quickly sprung up. (Remember, U.S. healthcare is private industry, but much of it is paid for by the government, e.g. Medicare, Medicaid). A big part of the problem is lack of accountability. There is little or no objective scrutiny in healthcare.  What do we get for our money?  Fifteen-thousand dollar a piece screws?

Specialist medicine has proliferated in part because Americans want to have “the best.” They like seeing the best doctors just as they like seeing the best sports teams. The problem, however, is what doctor to see when your self-diagnosis is wrong? The best at what?

Furthermore, while the idea of seeing the “best doctor” is appealing, there is no such doctor when it comes to non-pulmonary chronic cough, silent airway reflux and vagally-mediated neurogenic syndromes.

Today, people are skeptical and cautious, and at this point consumer confidence cannot be restored by the marketing claim, “We are the best.” Patients are rightly mistrustful of the current healthcare system.

People no longer believe that healthcare providers necessarily have their best interests at heart. It is now clear that patients must be their own advocates and that for-profit medicine leads to more attention to gain and less to quality patient care.

We pay almost four times more than any other civilized country for healthcare, and we rank 37th in quality of care. Last year, the price tag for U.S. healthcare was $2.7 trillion. Strip away the excesses and the price would probably have been closer to $700 billion ($0.7 trillion). That’s a lot of excess!

We need a healthcare system that is less fragmented and self-serving. Specialists often do what they do well, but nothing more.

If chronic cough, airway reflux, reactive airway disease, and (vagal) neurogenic syndromes are so prevalent—almost one-out-of-five (18%) Americans has airway reflux3 and falls into one of the above categories—then the current system is wasting massive healthcare dollars on inappropriate diagnostics and ineffective treatments.

Maybe we don’t need so many gastroenterologists, pulmonologists, and otolaryngologists. Maybe we need doctors who take better care of the whole patient with aerodigestive diseases. Reflux is the tip of an appalling iceberg.Integrated Aerodigestive Medicine

I have practiced integrated aerodigestive medicine for thirty years now. What does that mean? I am part otolaryngologist, but I know the parts of otolaryngology that most otolaryngologists don’t know. I am part gastroenterologist, but I know the parts of gastroenterology that most gastroenterologists don’t know. And I am part pulmonologist, but I know the parts of pulmonology that most pulmonologists don’t know.

I don’t practice all aspects of aerodigestive medicine, and I know my limitations. I have almost nothing to do with the liver, colon, heart, teeth, sinuses, etc.

I am an expert in the vagal system, and that includes the whole airway and the whole digestive tract. And yes, all of these parts are connected anatomically and functionally.

As I have become well known as an airway reflux expert, with expertise in non-medical treatment (namely, diet and lifestyle), more and more patients with esophageal reflux (GERD) have come to see me.

A common story is, “I had endoscopy, and I was told that I had Barrett’s esophagus. I was given a pill and told to come back in a year.” Apparently, most GIs think that the only treatment for reflux, no matter how severe, is a purple pill (PPI).

Unlike anatomic (organ-specific) medical specialties, integrated aerodigestive medicine is system-driven and symptom-driven. It combines elements of all of the overlapping aerodigestive tract medical specialties with a special focus on the diagnosis and treatment of airway reflux.  Further, as a preventative approach to wellness, integrated aerodigestive medicine emphasizes dietary health, lifestyle education, and behavior modification.

The aerodigestive tract must be treated as a unified system for which physicians are trained. In addition, precision diagnostics (e.g., laryngeal electromyography, airway reflux testing) are the key to accurate diagnosis, and at present, few physicians perform any, let alone all, of them.

So, if integrated aerodigestive medicine is a new “specialty,” who should see such a physician, and for what?  Shown below is a list of common integrated aerodigestive medicine symptoms.Here is a list of aerodigestive symptoms: allergies, asthma, burning tongue, chest pain (non-cardiac), choking episodes, chronic cough, chronic throat clearing, COPD (chronic obstructive pulmonary disease); difficulty swallowing, esophageal spasm, excessive throat mucus, food getting stuck, globus (a lump-in-throat sensation), heartburn, hoarseness, indigestion, laryngitis, laryngospasm, nausea, painful speaking (odynophonia), paradoxical vocal fold movement, post-nasal drip, regurgitation, shortness of breath, sinusitis, sleep apnea, throatburn, vocal cord dysfunction, vocal fatigue, vocal nodules and polyps, voice breaks, wheezing

The idea that people with these symptoms need to be seen by a committee of different specialist, one for each problem, makes no sense, particularly since reflux and vagal dysfunction are responsible for most.

For people who don’t have chronic cough but have another reflux-related or neurogenic symptom, you could read this by substituting painful speaking or burning throat for chronic cough and the information and approach will still be relevant.

A doctor practicing integrated aerodigestive medicine, as I do, must have certain skills and diagnostic technology: (1) Ability to obtain and interpret high-definition examination of the nose and throat (transnasal videostroboscopy) with still imaging; (2) Ability to diagnose subtle vocal fold paresis; (3) Ability to calculate an accurate reflux finding score;(4) High-definition esophageal manometry; (5) Ambulatory, double-probe, 24-hour (simultaneous esophageal and pharyngeal) pH monitoring; (6) Laryngeal electromyography; (7) Transnasal esophagoscopy; (8) Pulmonary function testing.

Let’s remember, the vagus nerve is the nerve of the entire aerodigestive tract. I am a doctor of the vagus, and therefore I am a doctor of the aerodigestive tract. I do not, however, practice medicine in a vacuum. I have a team of colleagues to whom I refer when appropriate.

It is a big team because I understand that I have limitations. I am not a sinus surgeon and sometimes one is needed; I am not a pulmonologist and sometimes one is needed, and so forth. No less than 25 stacks of business cards sit on my windowsill for those colleagues to whom I refer patients. They form a network designed to enable me to provide comprehensive care for my patients.

My aerodigestive medicine team: acupuncture, allergy, audiology, cardiology, dentistry, endocrinology, gastroenterology, general surgery (for antireflux surgery), internal medicine, otolaryngology, psychiatry, pulmonology, and speech-language pathology.

I refer to all of those professionals as appropriate, but I remain in charge of the overall health and well-being of my patients. I am the quarterback of the team. I call the plays and I insure that we doctors communicate for the benefit of our patients.

In the future, residency programs in integrated aerodigestive medicine will focus on chronic cough and other aerodigestive symptoms with the understanding that reflux plays a huge role in the severity of disease, and that environmental, dietary, infectious, neurogenic, inflammatory, and emotional factors act together. All must be considered as part of the problem, and the solution should be seen as unique for each individual patient.

In my opinion, a major overhaul of the healthcare system is needed. Health is not a commodity and should never be treated as such. Restructuring the American healthcare system will require a compassionate and un-corporate new paradigm. Integrated aerodigestive medicine provides an excellent model of efficient restructuring.





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