One of the most common requests I get is for a referral to a sleep apnea surgeon, particularly if they live in another state. Just like giving a referral for a lawyer or a plumber, there are a number of issues to consider. Some people don’t have access to any surgeons that perform sleep apnea procedures on a regular basis, or the nearest surgeon is located hundreds of miles away. Sleep apnea surgery is not commonly performed by all otolaryngologists, and even the ones that do may not perform these procedures on a regular basis. Here are some factors to consider when looking for a sleep apnea surgeon:
1. Academic or private practice?
There is a general perception that specialized medical and surgical care is better in academic medical settings. Yes, the academic medical centers teach and do more research, but clinicians in private practices can also be well trained and be more than competent. Ultimately, it is the individual surgeon’s passion and desire to constantly learn and apply these techniques that makes for a good doctor.
2. Do you do tongue base procedures?
Many otolaryngologists will do the nasal procedures and the UPPP procedure well, but not do any other procedures for the tongue base. If this surgeon is the only one that available for miles around, then you may not have a choice. My personal bias is that if you are going to be doing sleep apnea surgery at all, you should be well versed in all areas of the upper airway, especially in the tongue base area. Regardless, a good sleep apnea surgeon will know when an additional tongue base procedure is needed, but also what specific type of palatal procedure is needed.
3. How many have you done?
This is a requisite question that everyone is supposed to ask any surgeon, but there are inherent problems with asking such a question. First of all, it puts the surgeon in a defensive state, having to justify his or her qualifications on something that they do for a living. Do you ever ask a plumber how many drains he is unplugged? You may argue that unclogging a drain is not the same as major throat surgery, but there are certain similarities. Both the surgeon and the plumber has to know when and when not to do a procedure, which tools to use, how to explain to the patient/customer what’s to be expected, and how to deal with any potential complications.
Both surgeons and plumbers can be new on the job, but if trained properly, both can get the job done quickly and effectively. This is the point of residency, where residents perform high volumes of surgical procedures over many years. Ultimately, what is more important than the number of procedures is how well it’s performed. Doing a tonsillectomy 2000 times does not make you a good tonsillectomy surgeon. Learning how to do it properly, and constantly striving to improve the technique and the outcomes is what makes for a good surgeon.
The challenge in sleep apnea surgery is not so much the technique, but choosing the right patients to operate on, as well as knowing where in the airway to perform the operations. You could be the best UPPP surgeon in the world, but if you do not do any tongue base procedures, then your overall success rates will never be above 40%.
Honestly, the technical aspect of sleep apnea surgery is relatively straight forward. It is like an elevator operator that has worked for 25 years but was never asked to go to the penthouse floor. Would you ask him how many times he has pressed the penthouse button in his career?
Similarly, once a surgeon is properly trained, minor variations of surgical techniques in the throat are not difficult to master. If you were to ask me to do an appendectomy, I’ve done a dozen or so in my surgical internship year. But that’s not what I do on a regular basis, so I’m not going to offer to take out your appendix. If I read about a new UPPP technique, I can apply it right away and get good results from the start. Of course I’m honest with my patients that I have never done this variation before. But if you build up a good relationship with your surgeon, being the whether or not he’s performed the procedure is a moot point.
4. What are your results?
What is more important than how many procedures have been done is how effective are your results? If the surgeon has published a paper on success rates for UPPP, then you already know the answer. Most busy surgeons do not write papers all the time, but should know what their success rates and should be able to tell you.
5. What is your complication rate?
A good surgeon should know what his or her complication rate is. If a surgeons states that he’s had no complications, go to the next surgeon. Every surgeon, by definition, has had complications. There is a saying in general surgery, “If you do not have any complications, then you’re not being aggressive enough during surgery.
6. Who else do you work with?
A sleep surgeon should not be a one-man show. A good sleep surgeon will work intensively with various other physicians and medical health professionals. It has to be a team approach, like what is seen in comprehensive cancer centers. Proper follow-up and care are critical with any type of sleep apnea treatment, especially before and after any type of surgical procedure.
7. What are your options if the procedure does not work?
You should never undergo a procedure “just to see” whether or not it will work. Your surgeon should be able to give you a reasonable predicted success rate based on research findings, his or her experience, and your particular anatomy. There should be a discussion about the steps that may be necessary in the small chance that the procedure does not work. What are the expected potential reasons why the procedure may not work? This is a discussion that should occur before, and not after surgery.
8. Are you board certified?
It is a given that the for the most part, your surgeon will be board-certified in their main specialty, such as otolaryngology, oral surgery and general or plastic surgery. It takes one to two years to pass the written and/or oral exams after finishing residency, so a newly practicing surgeon may be a top notch surgeon, but not yet board certified. Your new surgeon may have trained with a prominent sleep surgeon during residency, be up to date on the latest research and surgical techniques, so if you go only by board-certification, you’re ruling out working with a potentially great surgeon. Not passing the boards usually reflects more on test taking ability, and not one’s clinical or surgical abilities.
Recently, more otolaryngologists are becoming double board certified (like myself) in sleep medicine. Honestly, I do not think being certified in sleep medicine makes me a better surgeon. I think the field of sleep medicine is fascinating, and only wanted to further my education and provide a more balanced form of care to my patients. However, you can still not be certified in sleep and be an excellent sleep surgeon, as evidenced by the fact that many of the pioneers of sleep apnea surgery are not board certified in sleep medicine. Sleep surgery is definitely within the realm of otolaryngology, and not sleep medicine, although there is beginning to be more cross-collaboration between the two specialties.
The vast majority of sleep surgeons will be otolaryngologists, but some oral surgeons also perform overlapping procedures, since they deal with the facial skeleton. There may be some general and plastic surgeons who have an interest in sleep apnea surgery as well.
Ultimately, what is more important than how may procedures I have done, or the training programs that I attended. It’s my passion for clinical excellence, and whether or not you and I develop a quality patient-physician relationship, where there is mutual trust and understanding. Obviously, this takes time and effort by both parties.