Tom Hanks, Spies, and My Dilemma As A Sleep Apnea Surgeon

One of my greatest challenges as a sleep apnea surgeon is what to do when patients require additional surgery because the first one didn’t work. With all surgical options for sleep apnea, there is always a small but significant number of patients when surgery helps partially or not at all. 
Patients know this before going into surgery. Rarely, you can also have complications. There are a number of technical reasons why this may happen, but the remainder of this discussion will focus on the dilemma that the patient and I face when presented with the possible need of more surgery. When initial operation didn’t work, I can’t help but to feel a sense of remorse as their surgeon feeling like I’ve let them down somehow. By all accounts, I did everything by the book. 
In a recent movie I saw called “Bridge of Spies,” Tom Hanks plays James Donovan, a high powered New York lawyer, who unsuccessfully defends a Russian accused of spying during the cold war. He escalates the case to the Supreme Court, arguing successfully that the accused should not be executed in case they need a bargaining chip with the Soviets. Sure enough, an American pilot gets shot down and stands trial in Russia for spying. 
The American government is contacted by the Soviets through someone in East Berlin to inquire about a possible trade. About the same time, an American student is captured and detained in East Berlin. Donovan is determined to negotiate the release of both captives in exchange for the convicted soviet spy.
Ultimately, Donovan easily wins the freedom of the American pilot. In everyone’s eye, this was a fair and equitable trade and something that was more than anyone could have asked for. But he couldn’t let this go. He kept pushing for the East Germans to free the American student at the risk of jeopardizing the deal he made with the Soviets for the American pilot’s freedom if not at the risk of his own life. He was accused of being an extremist. He fought with a dilemma of feeling like maybe he’s doing this to stroke his own ego or because he knew this is the right thing to do no matter what the cost.
My Dilemma as a Surgeon
Throat surgery is usually considered only after trying everything else for sleep apnea patients, including CPAP, dental devices, nasal surgery, diet and lifestyle modifications. Whenever the first surgery doesn’t help, patients will sometimes initiate the discussion, asking about the possibility of further surgery. In most cases secondary surgery helps. 
But what about patients who undergo multiple procedures without success? Some patients go through 3, 5 or even 10 surgical procedures before coming to see me. Whenever I ask my sleep colleagues, the general response is to avoid doing any more surgery on these type of patients. 
Is the Patient Crazy?
Whenever I see a long list of past surgical procedures, I admit that my first reaction is to recommend not doing any more surgery. What more can I possibly offer when even some of the top sleep surgeons in the country can’t help? Whenever I run these situations by my colleagues, I’m told consistently to avoid doing any more surgery, but I can see from the tone of their voice and facial expressions that they think the patient is addicted to surgery.
One way I’ve dealt with this situation is to recommend a second opinion. Some people end up going for two, or even three opinions. Invariably, they get conflicting recommendations and comes back even more confused and frustrated.
This brings up the question that all surgeons have to face: How far do you go to help your patients? Is there ever a limit to the number of surgical procedures, especially if you have a reasonably good idea what the problem is? Does having undergone ten operations automatically disqualify you from further surgery? Is it unrealistic to expect surgeons and patients to expect a “cure” after the first procedure?
Addicted to Surgery?
I thought that I could find all the answers since we are the “experts.” Patients are looking to us as their last hope. We as a profession should to able to help patients who have exhausted all their other options. But what should I do when my own profession tells me to withdraw care on certain patients that are “addicted” to surgery?
I searched amongst my colleagues, the research literature, and Google for some answers, but was unable to find any helpful suggestions. However, over the years, I began to see some insight from an unexpected source: my patients.
Something Besides Brain Damage
I began to see a pattern with certain patients that seem to be “addicted” to surgery. These people were relentless in their pursuit of a great nights’ sleep. Some patients were able to localize where the blockage was happening, but were oftentimes dismissed by their  doctors. In other cases, sleep physicians were puzzled when the AHI dropped from 60 to 1, but they didn’t feel any better. One common explanation by sleep doctors is that there may have been some brain damage or nerve damage in the throat that can’t be cured with surgery. 
However, whenever I examine these patients in the office or under general anesthesia, I see obvious persistent obstruction behind the soft palate, tongue base, or both. The previous procedure wasn’t strong enough. Sometimes, the epiglottis falls back or the soft palate flips back up in the nose during nasal exhalation. The latter mentioned conditions can’t be picked up by sleep studies. You can also see complete obstruction to breathing, but the pauses are so short that the sleep study doesn’t register any apneas or hypopnea. Oftentimes these patients are told that they don’t have any more sleep apnea and that their symptoms are either due to brain damage for some other unknown problem.
The Possible Difference Between Success and Failure
Whenever these patients decide to go on for more surgery, many patients end up finding the holy grail: a great night’s sleep. It may not be perfect, but it’s so significant, that some patients are in tears. Not all patients will ever reach this point, but in general, the more aggressively the patient pursues more surgery, the better the result.
Contrary to what’s generally believed by the sleep medicine community, in my experience, surgical failure does not lead to lessening the chances that you can use CPAP. Oftentimes, suboptimal surgery will allow patients to better benefit from CPAP and/or dental appliances. Extremely high CPAP pressures can be lower, making it more comfortable to use, and oral appliances may help better since there’s more space behind the throat structures. 
Sleep Apnea Surgery Is Not A One Time Deal
Patients and doctors still have the mentality that you need one good option to treat your sleep apnea. This is what ultimately breeds unnecessary competition between the various sleep professionals. What I’m finding is that for best long-term results, you need to consider mixing and matching multiple options, with periodic adjustments and even switching primary treatment options every few years. 
For obstructive sleep apnea, most patients can do well with only one procedure, but some patients will require more than one surgical procedure. One way of looking at this is to consider surgery for cleft palate, reconstructive procedures for children born with no ears, or patients with severe facial burns. In each of these situations, you start off with the knowledge that you’ll most likely need multiple surgical procedures, mixed along with physical therapy, hearing tests, psychologists, and various other supportive options that are usually needed.
If your initial surgery was successful but stopped working after a few weeks, most people will say that the surgery didn’t work. However, the fact that it did help significantly, even if only temporarily, means that you addressed the right area of blockade, but the surgery was not aggressive enough. At this point, an examination in the office or sleep endoscopy usually reveals what more needs to be done.
Questioning My True Motives
Tom Hank’s character struggled with whether or not to “go for it” placing both captives and even his own life at risk. He could have taken the easy way out and settled for only the pilot. In the same way, the easiest and safest option for me is to tell the patient that I don’t think anything more can be done. But if I know that there’s persistent obstruction behind the soft palate and there’s a chance that more surgery can help, what’s the right thing to do? Settle for good enough and go back to CPAP, or agree to further surgery with no guarantees of success? Am I offering further surgery because it’s in the patient’s best interests, or to boost my own ego as a sleep apnea surgeon?
Granted most patients won’t ever have to face this dilemma. But this situation happens often enough for me to question my own motives every time it happens. Unfortunately, there are no textbooks, research studies, experts or other resources to help me with this particular issue. Until something comes along, the only resource I have to to develop a strong relationship with my patients, and come to an individual decision based on the available evidence and mutual trust.
If you are faced with this situation as a patient, would you rather that your surgeon play it safe or would you rather that he or she did everything possible? What do you think?

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3 thoughts on “Tom Hanks, Spies, and My Dilemma As A Sleep Apnea Surgeon

  1. It’s ridiculously frustrating to hear doctors speak like the one’s that you’ve spoken to. Before my OSA diagnosis, I was told that it was all in my head, that I’m one of those patients who’ll have lots of little problems, or that I was simply anxious. They were dismissive in other words. Worse yet, at the other extreme you have doctors ordering lots of unnecessary and potentially harmful tests like cat scans in a wild goose chase for a diagnosis.

    The right response is somewhere in the middle. First doctors need to understand that patients don’t understand medicine. They don’t understand that medicine changes and that just because you can’t offer them surgery now doesn’t mean that’ll be the case in 5 years. They don’t understand that not every problem needs to be fixed. They don’t understand that sometimes the fix is worse than the problem. That routine surgery sometimes fails and fails spectacularly. That surgeries can’t be done indefinitely and that it becomes riskier as you get older. And that when it fails, you c an’t go back to the way things were. Doctors know these things, of course, and when refusing to do surgery they should be explaining these issues to patients or at least ensuring that they have an understanding of these issues before deciding to proceed. And sometimes patients do indeed suffer from mental illness. As you know, someone working on this problem should be especially prepared to handle this problem since it’s a comorbid complication of OSA.

    The right response, then, is to refer patients to a psychologist for education and evaluation or at least provide brochures and other reading materials covering these topics. Some have advocated that psychologists should be incorporated into regular primary care practice even. Referring patients for mental health treatment requires a certain tact of course, due to the stigma against mental health. It is not the doctor’s job to determine if an individual suffers from illness and they should know that they are typically grossly unqualified to make that diagnosis. Instead, they should emphasize the need to humour them, just to rule it out, emphasize the educational aspect which they are unequipped to handle, the comormid association, and perhaps even deemphasizing the mental health aspect and refer to them as health care coaches instead. In fact, I advocate that just as consumers hire Realtors to hire houses, big typically irreversible transactions, consumers should consider hiring a medical coach as well, that is someone who understands these medical issues and who can establish a trusting relationship that helps evaluate all the options available. That is a relationship that a doctor cannot offer, due to time constraints and more importantly because of various biases like conflicts of interest and limited treatment modalities.

    At the end of the day, said patients are still more prone to failure and that puts the doctor at risk in various ways, from malpractice to feelings of regret when things go wrong. Sadly, that’s another major reason that doctors turn away patients. It is my opinion that if a doctor is going to do this, that they take the time to educate patients on these medical issues so that they don’t turn to desperation doctor shopping. Ultimately, they will find a doctor who will treat them and survivorship bias is not usually working in their favor at that point. The kind of doctor who will treat a patient like that is usually not one that you would want to put your trust in. Most physicians don’t realize it, I think, but when you blindly turn away patients often times they internalize the rejection, which further complicates their medical afflictions. That is, even when it’s not personal they don’t perceive it that way because doctors aren’t always clear that it’s not. Again, this is a place where a psychologist can really help out. I know doctors hate the idea of single payer but this is also one situation where it would really help, to have a set of medical professionals who are obligated to treat all patients, the group of untreatable red flag patients that have no where else to turn.

  2. Dr. Park, I really appreciate your thinking on this issue. In my own case as one of your patients, although I’m sure that the surgeries you’ve performed on me had a positive effect I’m also pretty certain that I still have airway closure issues especially if my sleeping position becomes less than optimal. I’ve caught my throat closing off if I fall asleep on my back on the couch, for example.
    I’m the type of person to not let things go if they’re ‘pretty good’ or ‘not too bad’. I’d like to give myself every opportunity to maximize my health and lifespan. I don’t see that as being obsessive – it’s the same attitude I have if there’s a problem with my car; I don’t just let it go until it gets worse.
    At some point I think it would be a good idea for us to do a sleep endoscopy to see what the state of affairs is in the vicinity of my palate, tongue and throat.

    Thanks again for your expertise and your genuine care about us as patients. It’s a winning and not common enough combination.

    John Cronk
    Vancouver Washington

  3. Using cpap I had a seizure 10/1/12. I lost my job as an over the road driver. After a seizure you have to be seizure free and med free for 10 years. I have found that I had the same side effects as 02 toxicity. Found billions in fraud tied to cpap. Now on disability and can’t driver till seizures are controlled. One drug neurologist wanted to put me on was 750$ a month. Obama care doesn’t cover it. My wife and I used to clear over 2,500.00/wk. Now about 2,400/wk. Lost our house, my life ins ability to work, and can’t even ride with my wife because I’m a safety hazard. 6/8/12 I sleepwalked out of semi while my wife was driving about 60mph. My granddaughter pulled hose off the face mask trying to wake me up. She was 11 at the time. I wonder how the west was won without cpap. I’ve used natural remedies for hay fever. Took shots to build my immune system, best sleep I got was learning self-hypnosis, I use oil on my feet made by Young Living Essential Oils​ which helps with the itch. I feel energy in my hands like book hands of light by barbra ann brennan​. Read The Road Less Traveled and Beyond: Spiritual Growth in an…​ The body system is not a one size fits all. I think a spirit force kept me alive when I rolled down the highway. Minning the Silver Lining​ author helped me learn self-hypnosis. People of the Lie: The Hope for Healing Human Evil​ just another example of how the mind works. Christ I think said Faith, Hope, and Love with Love being the greatest of these. I saw my left arm grow out to be even with my right. I see auras, have had the out of body experience. read Book Many Lives Many Masters​ . Also, read book Australia Down Under by Marlo Morgan about living in the outback. People were healed by the group. Sure they still died. But, the point in my view is they lived.