My Dilemma With Referrals
September 11, 2011
One of the most common requests I get is for a referral to another ENT (otolaryngologist) that shares in my philosophy when treating sleep apnea. To be honest, I’m uncomfortable making any recommendations, because as far as I know, there are no other ENTs that think the way I do. So far, I’m not aware of one ENT physician that has even read my book (please correct me if Im wrong). There are lots of excellent ENTs that are very good at handling obstructive sleep apnea—many are my mentors and people that I learn from. But whenever I bring up the philosophy of my sleep-breathing paradigm, they all say it’s interesting, but ask if there’s any evidence.
The problem with a paradigm is that it can’t be proven. There are so many pieces to the puzzle that it would take hundreds of years and billions of dollars to perform necessary definitive studies. We give water for dehydration, but so far there are no randomized, prospective, placebo-controlled trials showing that given water actually improves dehydration. In addition, water is not FDA approved for dehydration, which is a clinical diagnosis. When there’s no evidence, we use common sense and reasoning in making clinical decisions. However, modern medicine fails by separating out all the various body parts and systems into separate specialties. Yes, doctors like to say that we look at the whole person, but how much can your doctor truly learn about you in a 15 to 20 minute consultation?
My sleep-breathing paradigm actually pieces together hundreds if not thousands of studies that are already out there, connecting the dots. One of my main goals is to strengthen the links between sleep apnea and various other medical and mental health conditions through rigorous studies. For example, there are numerous studies linking reflux to obstructive sleep apnea, reflux to chronic sinusitis, and chronic rhinitis to reflux. If they’re all linked, why can’t sleep apnea be linked to chronic sinusitis? In fact, I presented a poster many years ago showing that people who undergo nasal or sinus surgery with recurrent symptoms or disease had an almost 80% rate of significant obstructive sleep apnea. Now that I’m looking for sleep apnea beforehand in people with chronic sinusitis, the rate of needing to go on to nasal or sinus surgery has dropped significantly. The same analogy applies to ear infections, depression, anxiety, heart disease, irritable bowel syndrome, psoriasis, nocturia, high blood pressure, or diabetes.
The good news is that there are a handful of sleep doctors that do “get it.” I’ve interviewed some of them on my Expert Interview teleseminar series. Most sleep doctors are very good at what they do, but will probably disagree with me on some fundamental principles when it comes to the airway and sleep. For example, I see a few patients every year who are chronically tired and are given a diagnosis of idiopathic hypersomnia by the sleep physician, with a completely normal sleep study (AHI is 0). Typically, they’re prescribed stimulants. When I examine the airway, I see that the space behind the tongue is very narrow, especially when flat on the back. I refer the patient to a dentist who makes a mandibular advancement device, which improves the patient’s symptoms significantly. Sometimes, even helping the patient breathe better through the nose can “cure” the problem.
So the next time you ask me for a referral, my stock answer will most likely be, “I don’t know.” I may know someone I met at a national meeting or recognize prominent names from published studies I’ve read, but that doesn’t mean that they’re going to agree with my practice philosophy. I’ll continue making recommendations based on the information that’s given to me, and if I happen to know someone that I trust, I’ll make that recommendation. Just like getting a referral to a good lawyer, there’s no quick and easy answer. You have to do your research, ask around, and go with your gut instincts.
Come to think of it, as far as I know, there are no known studies showing that going to a doctor by referral from another doctor results in improved clinical outcomes.