My Dilemma With Referrals

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. 

Please note: I reserve the right to delete comments that are offensive or off-topic.

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5 thoughts on “My Dilemma With Referrals

  1. Hi Dr. PARK,

    You big pictures of linking all the dots from various symthomps to sleep breathing exactly map to what float in my mind for some period of time. Classification of various syntomps in medical fields to treat each type of medical symtomps prove to be just targetting on surface of each problem. Be able to view from the big pictures is an art that much more than science. Nobel Prize in Making.

    Not all engineers have the same skills, all ground experiences are not the same, a guru speaks more than just skills and experience….BUT WISDOM!

    Truthly,
    Malvin

  2. you may be it. the only one. I was telling my allergist yesterday that I feel like I have to take the bits and pieces that I get from each of my specialists (and from my own research) and put it all together myself because no one of them can see those pieces all together for the big picture. Sleep Medicine as a specialty seems to be very fragmented, with a lot of growing up to do. you are about the only one who puts it all together and sees the forest for the trees. and that’s saying something because I’ve been to UCSF and Stanford. send those patients to me and I’ll tell them they don’t need a second opinion.

  3. Fortunately there are a few sleep doctors and ENTs that do get it. Unfortunately there are a few sleep drs. and ENTs that give out contrary info. and that’s a big step backwards for all of us.. Especially if you have UARS they look at your sleep study and immediately say you don’t have sleep apnea, and if they are not well-versed in UARS it will be a wasted visit.

    Recently my sister saw an ENT. She snores and has typical OSA/UARS problems and he said she was fine and did not do an endoscopic exam. Another person with severe snoring and congestive heart failure was told by his primary physician he did not need a sleep study. I have UARS and so does a friend of mine. The chief of sleep medicine at one HMO told me I was fine. My friend went to the same clinic and was told by a different sleep dr. she was fine even though she has fibromyalgia. (This was at a non-accredited sleep center ) . My current sleep dr. at a different clinic (accredited) recognized UARS and has been a real advocate for me..

    Of my family and friends, a lot of them have OSA/UARS. Symprtoms range from severe insomnia to congestive heart failure, heart disease, high blood pressure, depression/anxiety, psoriasis, and chronic fatigue. I have given them all of the info. from Dr. Park and Dr. Krakow and most have not tried to improve their breathing and instead choose pharmaceuticals.. All of them say they do snore. I think they are just overwhelmed by what you need to do to get well and so they choose denial. Also they listen to their doctors who are not familiar with and do not endorse sleep-disordered breathing.

    I’m very disappointed that more people are not getting accurate information from both sleep medicine personnel and primary physicians.

    Thank you, Dr. Park, for your continued passionate endeavors and support. At this time you are the only central location for sleep breathing information that I know of and your fellow-believers appreciate it.

  4. Do you have any expiriences? I’m being tetaerd for depression (zoloft) and I was told to examine my thyroid gland since it’s function has some effects on our mental state, i.e. can cause depression, or cause fast paced heart rate (which is common in panick atacks I guess..) Tomorrow I’m going to take the tests, and discuss them with my therapist probably the next week. So I’d like some feedback I know those two are connected since thyroid is a gland and it’s hormons effect us in many ways, but I’d like to know some more specific information. What were your symptoms before you took the tests, what did you do if your tests for thyroid disfunction were positive, did the therapy improve your state etc Tnx!