Presidential Address of Jamie A. Koufman, M.D., F.A.C.S.
American Broncho-Esophagological Association (President 2008-09)
Presented at the Annual Meeting of the Society, Scottsdale, AZ, April 29, 2009
Dear members and guests of the American Broncho-Esophagological Association, it has been my honor and pleasure to be president of this society. During this past year, among other things I have examined the advantages, disadvantages, and influences of medical specialization on healthcare in America with a particular focus on how this impacts our patients with aerodigestive tract symptom. The title of my talk is “Specialization: When Being the Best Isn’t Good Enough,” because I believe that medical over-specialization is a problem. Many complex patients have a committee of non-communicating doctors with no one doctor actually taking responsibility for the patient’s care. Here is a multiple choice question for your consideration that makes the point:
A 55-year-old school teacher has chronic cough and vocal fatigue since onset of symptoms with an upper respiratory infection in 1997. Which is the best doctor to diagnose and treat her problems?
E. None of the above.
With a normal chest x-ray, the patient’s primary care doctor sends the chronic cough patient to a pulmonologist for evaluation. The lung doctor does a PPD, spirometry, bronchoscopy, and finds nothing. Thinking that the patient might have “atypical reflux disease” (laryngopharyngeal reflux, LPR), the pulmononlogist sends the patient to an otolaryngologist who examines the patient and concurs that the diagnosis may be LPR. So, the otolaryngologist refers the patient to a gastroenterologist who performs upper endoscopy, and finding a normal esophagus, declares the patient does not have reflux disease. The GI doctor speculates that the likely cause of the patient’s cough is allergy, and therefore, the patient is sent to an allergist-immunologist. The latter physician, finding no allergies, sends the patient back to the primary care physician. So, the correct answer to the question above is “E. None of the above.”
You may not know this, but chronic cough is one of the most common symptoms for which a patient seeks medical attention in the United States. Chronic cough patients, most often referred to me by gastroenterologists and pulmonologists, account for 20% of my practice. Indeed, in my experience, these patients are often passed from doctor to doctor; and even though they are referred to me for evaluation for LPR, not all of them have reflux, but the majority do. There are many patients who have reflux as the only cause of cough and those patients, even on proton pump inhibitors and other medications, may continue to have cough for as long as they reflux, even neutral-pH reflux. Such patients often will tell you that reflux is the cause of their cough. They may report, for example, that they have regurgitation when they bend over, that they cough after meals, and that they sometimes awake in the night from a sound sleep coughing violently and gasping for air.
In addition to LPR-related coughers, there is a significant group of patients who have “neurogenic cough,” which is a kind of “sick nerve syndrome” usually related to a post-viral vagal neuropathy (PVVN). People with PVVN and neurogenic cough usually have a history of having had an upper respiratory infection weeks, months, or years prior, around the time of the onset of symptoms.
The typical pattern of neurogenic cough is daytime (all day long), but not at night. Specific things like change in temperature (e.g., going from warm to cold), and certain odors (e.g., perfume, diesel fuel or gasoline smell) may precipitate cough. In addition, such patients often describe having a “hair trigger” cough, and that speaking or chuckling may precipitate coughing. When patients have cough associated with voice use, it is almost always a neurogenic cause. It is important to note that neurogenic and reflux-related cough patients form a very large population of patients, and that these patients are essentially without a doctor/specialist.
Specialization is a very America idea, in spite of the fact that it results in fragmentation of medicine; after all, everyone wants to see the “best.” So, you do actually get things like this inane example: “Yes, I’m the very best doctor in the country for doing a stapedectomy on the right ear for otosclerosis. And no matter; if you have similar trouble in your left ear, my partner who happens to be left-handed, is the best surgeon in the country for fixing otosclerosis of the left ear. Between us, we are the best if you have otosclerosis in either ear.”
The problem with patients who have symptoms like chronic cough or other reactive airway diseases is that the patients often don’t fit any of the specialists’ boxes. Just think about it for a moment: globus, dysphagia and many otolaryngologic symptoms cross both anatomic and medical specialty lines. And the concept that diseases fit within the boundaries of our medical specialties – nose/sinuses, throat, lung, esophagus – is preposterous. It would seem that the creation of certain medical specialties was predominantly for the convenience of physicians.
Reactive Airways Disease
Paradoxical vocal fold movement
Vocal cord dysfunction (“VCD”)
Neurogenic (“neuropathic”) cough
Gastroesophageal reflux disease
Laryngopharyngeal reflux (“silent reflux”)
It is likely that allergic rhinitis, post-nasal drip, vasomotor rhinitis, paroxysmal laryngospasm, paradoxical vocal fold movement, asthma, and neurogenic cough are all manifestations of reactive airway disease and that reflux is a common feature in many patients. It is amazing to me how many patients have sinus disease and asthma related to LPR.
As I was flying out here for this meeting, I opened my New Yorker Magazine (dated June 1, 2009), and found an article, “The Cost Conundrum” by Atul Gawande. This was an amazing article and coincidence, and a real eye-opener. The bottom line: Overutilization of specialists was one of the main reasons for the high cost of healthcare in the United States. Here is essence of the story. In 2006, the median income for McAllen, Texas was $12,000; however, Medicare spent over $15,000 per enrollee in McAllen. In nearby El Paso County, which has similar demographics, only $7,000 per year was spent on each Medicare enrollee.
But by all contemporary metrics, McAllen’s health care was not as good as El Paso’s. Healthcare services in McAllen were found to be grossly overutilized. In McAllen, for example, if you had chest pain having eaten 16 tacos, instead of getting an antacid in the emergency room you might be admitted and end up having a cardiac workup including cardiac catheterization. If you had numbness of your fingers, you would probably end up having nerve conduction studies. As a matter of fact, overutilization also resulted in high rates of unnecessary surgery.
In McAllen, there was this complex medical network in which most patients went from doctor to doctor to doctor, having “all of the most advanced tests and treatments.” It was profoundly wasteful. Dr. Gawande concluded, “Someone has to be responsible for the totality of care; otherwise, you get a system that has no brakes.”
Integrated Aerodigestive Medicine
It is my belief that reactive airways disease is really just one complex syndrome and we as otolaryngologists need to be responsible for managing patients who have diseases of the nose, sinuses, and aerodigestive tract including the esophagus and lower airway. For us to defer to gastroenterologists and pulmonologists makes no sense whatsoever as many of our patients are not going to get effective treatment at the hands of those specialists.
We need to create a new “specialty” perhaps called “Integrated Aerodigestive Medicine.” This is not a new concept, the idea of a holistic approach to the management of patients with confounding symptoms. Its time has come. I urge you, my colleagues, to learn more about things like neurogenic pain, chronic cough, swallowing disorders, “asthma,” and reflux. These conditions are all within our domain.
It is also time for otolaryngologists to begin routinely assessing the aerodigestive tract using modern technology. When Chevalier Jackson invented modern endoscopy, over a hundred years ago, he did not accept limits based upon arbitrary anatomic subdivisions. He examined the esophagus and the lungs, larynx, and sinuses as though they were all part of the same system. They are. With the availability of distal chip technology, modern endoscopes allow complete evaluation of the aerodigestive tract, including biopsies, in the comfortably awake patient … in the office. Manometry and reflux testing are also essential. These are all part of our specialty.
At present, esophageal cancer and precancer are epidemic, and it is our responsibility to screen our patients for potentially life-threatening neoplasia. As a matter of fact, attention to the lifestyle/dietary issues and needs of our patients also now needs to fall within our domain. It is time for otolaryngologists to become “integrated aerodigestive tract physicians” – otherwise we will continue to fragment our own patients’ medical care.
Gawande, Atul. The Cost Conundrum. New Yorker Magazine (June 1, 2009)
www.refluxcookbookblog.com (“The Missing Link”)