Our 18th episode provides an inside look at the interesting speciality of Neurotology! Join us for an interview with Dr. Darren Tse, a Neurotologist at the University of Ottawa, who is sub-specialized in disorders of the vestibular system.

Show Notes

Hannah: 

Hello and welcome to The Oto Approach, a podcast created by medical students for medical students, to teach you about all things Otolaryngology.  I'm your host, Hannah Brennan, and today we’re going to be joined by Dr. Darren Tse! 

Dr. Tse is an Assistant Professor in the Department of Otolaryngology – Head & Neck Surgery at the University of Ottawa.  He completed medical school and his Royal College of Surgeons in the UK before returning to Canada and completing residency at the University of Ottawa.  He specializes in Neurotology, with a sub-specialization in dizziness, vestibular disease and balance disorders. He founded the Multidisciplinary Dizziness Clinic and the Rapid Access Dizziness Clinic at the Ottawa Hospital both of which specialize in tertiary level care of patients with chronic and acute dizziness. He is the Director of the Ottawa Hospital Vestibular Lab and recently helped establish the Vestibular Audiology Clinical Assessment and Testing Clinic where specially trained vestibular audiologists assess and test patients with dizziness.  His research interests are focused around vestibular disorders such as recurrent Benign Paroxysmal Positional Vertigo and the role of cannabis in the treatment of dizziness, as well as the pathophysiology and treatment of functional disorders like Persistent Postural Perceptual Dizziness. 

Thank you so much for joining us today Dr. Tse, we are really looking forward to learning more about your career and experience this episode. So why don't we go ahead and get started with our first question.  Could you tell us a little bit about yourself?

Dr Tse: 

Yeah, So I guess I am originally from Toronto, and I took the interesting course in the late 90s to go from high school and do medical school in England. I guess the original reason for that was to try and avoid undergrad, want to kind of fast forward to being a doctor as soon as possible and England gave the opportunity to do that seen medicine over there is an undergraduate degree. And that all kind of worked out okay, so I was a doctor by the time I was 22, 23, which kind of makes you grow up kind of quickly. You go from doing a couple of years like every university student partying hard and not doing very much work to suddenly finding yourself with clinical duties on the wards. So, it’s an interesting way of approaching it. So, I did end up saving some time but then eventually through various journeys and decisions I ended up back in Canada after, it was 2006 or so. So, I didn’t end up saving much but did my residency here in Ottawa with quite a number of years of being a doctor so I guess it kind of helped. And then the rest is history really, I finished residency here and then started working.

Hannah: 

It is really interesting to hear about your journey through medicine in the UK system and that introduction of responsibilities much earlier on.

Dr. Tse:

Yeah it is an interesting system, while you become a doctor earlier on, you spend much longer before you chose your specialty field. And I think their system has shortened a bit since I was last there, but you spend quite a number of years doing either kind of medical or surgical training before choosing a residency, which over there is like a registrar, it is called registrar. So in some ways it is fast forward but in other ways it is much less direct than over here because you know, straight from medical school you are into residency and then you are out. It is an interesting system and there are pros and cons to both probably. And then of course even though I am Canadian I came back here as an IMG. So, it is always a bit of luck in terms of finding a residency when you are coming back 

Hannah: 

Right, Can you tell us a little about what originally drew you to otolaryngology?

Dr Tse:

Yeah, so when I was in England maybe about 2002, that probably give away how old I am, but I was doing this kind of surgical rotation that they had back then, they do about 4-5 years of surgical rotations before you can actually do ENT or urology or whatever. So one of the rotations I did was ENT and I actually- I’ll admit it straight up I didn’t really enjoy that rotation, and that was 6 months so you get a real big chance you get your teeth sunken into something when you do something for 6 months. So, after that rotation I wasn’t that impressed. ENT over there where I was, is kind of different than what ENT is like over here. Actually, I really enjoyed my six months doing oral maxillary facial surgery, which is all the head and neck cancer that ENT does here which was done by the OMF guys where I was. That is where I got my exposure to head and neck cancer, which is often one of the cool parts of ENT that people really like when they don’t know too much about ENT. So, I almost went back to do dentistry, cause you had to be a dentist and a surgeon to do OMF in England. I’m this close to going back to dentistry school then I decided I really didn’t want to do that. And then I left England and I came back and I really didn’t have a lot of things I could apply for as IMG as well as my kind of CV. So, ENT was one of them and so ENT IMG spot in the whole country. Orthopedics was another. I actually did a ton of orthopedics training in England. I couldn’t apply to OMF because I was not dental trained. So, it was like ENT or Ortho basically. So, I applied for everything I could, I ended up only interviewing in 2 places and ended up in ENT which I was very happy with and never regretted that decision. So really it was a combination of what I was kind of interested in and what my opportunities were at the time. So that’s how I ended up there. 

Hannah:

That’s great to hear how you ended up in ENT. It seems like because of the breath of the specialty many people can find interest there and their niche.   

Dr. Tse:

Yeah, I got to say, in ENT it is very varied and it is very functional. Everything you do is super functional, with hearing or swallowing it is something that affects people every day, a lot of things that you take for granted when everything is working properly. There are even cosmetic considerations. There are so many varied aspects of ENT. You can be very heavy surgically or you can not be as heavy surgically. So, there is a lot of opportunity for variations in practice even from when you start to when you finish, you practice can change a lot. It is really quite a nice specialty, good call, good lifestyle balance that’s really good. You know, it pays well. It is actually a very good surgical specialty if you are going to pick one. 

Hannah: 

Absolutely, there are so many positive aspects. Could you tell us a little about how you decided to focus your practice and the process of establishing the dizziness clinic?

Dr. Tse: 

Yeah, so it is really interesting because dizziness and vestibular is not really taught well in the program at the time and I think that was family similar with most programs. So, it is definitely something you didn’t gain as much knowledge in or practice with during residency. I had initially finished residency and decided not to do a fellowship because as I already said I had been a doctor for almost 20 years. I didn’t really feel the need to go back and do more school. So I actually set up a mini practice down at the Winchester Hospital, which is just south of Ottawa. And I started getting into dizziness because I had a lot of dizzy patients. It is a very common referral. It’s a referral that a lot of ENT’s don’t like seeing. It’s not because they don’t like it but because they don’t know too much about how to approach it and they don’t have the time they would like to spend to deal with it properly. And it is one of those frustrating aspects of ENT. Every specialty has sort of their frustrating subject matter and dizziness is definitely that for ENT. I’m seeing a ton of these patients and I’m the new guy, so that’s where all the referrals go. So I was just like these people are very un-helped. It’s super interesting and again extremely functional. I just started getting really into it then I came up with the idea that the best way to see these patients is to partner with a neurologist because these patients are constantly bouncing back and forth between ENT and neurology usually with a year, year and a half wait in between, often not getting great service or just one half of the story from one side or the other, seemingly fairly arbitrarily who gets referred to where and its kind of an area that is ripe for multidisciplinary care. We all know how cancer clinic works and how great that is, so why can’t we do that with this. And actually, the inspiration for it was from Dr. John Rutka’s clinic at the UHN in Toronto, which he runs with a neurologist and a psychiatrist, which is a cool set up. So I had the idea with the chair at the time that we would try to set something like this up and he was very encouraging about it and we visited Toronto to see how they do things and we kind of set up our own clinic. I happened to come across Dr. Lely at the time, who was also a new neurologist who was interested in dizziness and vestibular disorders from his side of things. And that was just a stroke of luck really because we got on super well we were about the same stage of life and then we just kind of ran with it. The whole thing started maybe about 10 years ago, with some happy coincidence, some good timing, and just filling a niche filling a need that where was not and people were very supportive of it and it just kind of grew from there

Hannah:

That is cool that you were able to focus on such a functional disease and have the time and resources to address it in a unique setting in the multidisciplinary clinic. 

Dr. Tse: 

Yeah so, it’s great because what these patients need is time. They need time to tell you about their problem. You need time to work through it all and figure it out. Sometimes these patients have been dizzy for a very long time. You can’t figure that out in a 7-and-a-half-minute consultation no matter how much you want to. So we set it up where we see every patient like cancer clinic, an hour, an hour and a half, go through all the testing, just try to get to the bottom of these patients who have been dizzy for a very long time and you know, no one is making that up. Right like, people are not working, not living their lives they don’t want to do that. And so, it was definitely a way of assessing and treating these patients that was very needed. And from our side it was just amazing to learn from somebody else. Impart my knowledge to his side and for him to impart his knowledge on my side, it probably happened more the other way. I probably learned a lot more from him than he learned from me. And then sort of like becoming like a symbiotic organism here or a dizzy organism, which doesn’t have these arbitrary silos of ENT and neurology, or peripheral and central because dizziness doesn’t work like that. You can’t arbitrarily split it down the middle, everything is connected to everything else so it was just the perfect way of approaching this complex area. 

I think if you speak to anyone who works in multidisciplinary setting it is very professionally fulfilling, to share your expertise and learn from other people and together make a difference. That is the biggest part of it from a professional point of view, and from patients they said you are the first person to spend more than 10 minutes listening to their story. Even if we can’t help them, which a lot of time we do but sometimes we can’t at least they know that somebody really tried and maybe given it a name and maybe some treatment suggestions. So it goes a long way for some patients. 

And you know that the fringe benefit for me anyway, I’ve learned so much from these patients over the last 10 years that it has changed my own practice. I went from being barely general ENT with a focus on seeing dizzy patients once a week, to almost being 90% dizziness, so I see a lot of dizzy patients every single day. And it doesn’t actually get boring, for most ENT’s that would sound horrible, but for me I kind of enjoy it and to be able to use all that experience to very quickly diagnose people, it then becomes more like pattern recognition a lot of the time. Sometimes people throw the odd curveball. But in my own practice it has changed so significantly. I would consider myself almost half a neurologist now in terms of doing things like treating headaches, things like that, things that ENT’s would not normally do. I just kind of grew my own professional skills to suit the patients that I see, so that is pretty cool professionally in terms of becoming so varied in terms of what I can do.  

Hannah: It is really interesting that you can shift the focus of your practice later on in your career and it doesn’t need to be a decision that you make in the beginning. 

Dr. Tse: 

Yeah, I think people practice patterns will shift constantly throughout their career, from beginning to end. At first you make start to get heavily specialized then you might spread out then you might specialize in something else. Interest changes, things change practice patterns change, so it is good to be flexible and ENT definitely allows you to do that. 

Hannah:

Absolutely, could you tell us what a typical week looks like for you?

Dr. Tse:

So it is just seeing dizzy patients. So, I guess my practice is a little more medical than surgical. I do have a small to medium sized surgical practice doing endoscopic ear surgery, which is a thing I started doing very recently. The hospital was quite encouraging because it was something that had not been offered in our region yet, and it is kind of the new trendy way of doing ear surgery right now, kind of like when endoscopic sinus surgery came out. Overall, everyone was on board and we started a program doing endoscopic ear surgery, which I am no pro at yet. But it has been great to create and develop new surgical skills, even at this stage in my career which is really cool. But other than that, I spend a lot of days in clinic seeing patients for mostly kind of dizziness, migraine, hearing loss, sudden hearing loss is a huge thing since COVID started. We see a lot of sudden hearing loss, and then other ear complaints. So, I am almost completely otology/neurotology focused. I still have patients with other aspects of ENT, that are either old patients of mine or working through referrals from even 2 years ago. But generally, my practice is mostly otology and neurotology focused now. 

Hannah:

That sounds like a very interesting and rewarding way to structure your practice. What would your favorite or most rewarding aspects of your practice?

Dr. Tse:

Yeah, I think being able to tell patients exactly what the problem is, what caused it and what we can do about it, for something that has been not diagnosed for maybe a long time by many other people is definitely rewarding. Then even more rewarding then that is when they are better when you see them the next time. And I know that the residents get the impression that none of these patients ever get better, but that is because they don’t see the follow ups. The patients mostly do get better. Some don’t, but most do get better, at least good enough to get back to work and do the things they want to do. So, that is definitely what kind of keeps you going. It would be really difficult to keep doing something every day where no one ever got better, even if we were given them the satisfaction of a diagnosis. It would still be difficult to keep doing it, if you aren’t making anyone better. So that is definitely one of the rewarding aspects of it. So, I already mentioned working with other professionals, learning from them expanding your own scope of knowledge way past where it really should be as in your particular specialty, breaking down silos of knowledge, trying to spread those airs of knowledge to colleges and family doctors, whoever wants to learn, and that’s been one of the big missions that we have had. I think wee see tangible areas of success, now after 5-10 years of just spreading the word and spreading the expertise around. So that has been another rewarding aspect of it too, just trying to get everyone on the same page and spread the knowledge around.

Hannah: 

On the other side of things, what would you say is the most challenging aspect?

Dr. Tse:

Challenging ones are always the challenging patients, the patients where you don’t know and can’t figure it out. Then you’re just another in the long line that they have seen that don’t know. Then you don’t know how to help them and they don’t get better. That is always a difficult situation. Luckily it doesn’t happen that often, but it still definitely does happen and that is always challenging. The biggest challenge probably for everybody is working with the resources that we have. We are lucky enough here in Ottawa. We are getting a brand-new hospital, who knows when it actually will be built but we are getting a new hospital with a new clinic, because our current clinic is pretty old. And so that’s nice but everybody has resource restraints. COVID definitely didn’t help it but COVID didn’t create the problem, just made it worse, so that’s a theme you will hear all across all areas of life, not just healthcare, but especially in healthcare. And that is always a big challenge on a day to day, trying to deal with resource issues. Just working through one patient at a time and you have to do what you can do but that is alwasy a challenge. 

Hannah:

I can definitely see how helping patients and improving their quality of life is the most rewarding, and it can be the most challenging when that path to helping them and getting to the root of the issue is longer and difficult. We briefly mentioned your research interests in the introduction, could you give us some more insight into your current research? 

Dr. Tse:

Yeah so one of the advantages of starting a new program is that you can design things from the ground up, so one of the things we make sure was that when we started the dizzy clinic and later the rapid access clinic, which is like a sister clinic, we set up basically a kind of data banking project where we would collect a whole bunch of symptom score and other information from patients and keep it in a big anonymized database, so then we can mine that database later, for information, outcomes, trends, whatever. So that was a good bit of insight that we had to do that. Because later, 4-5 years later it starts to bear fruit, in terms of figuring out why are these patients so chronically dizzy, what is making them that way, where some patients get better, we are trying to figure out why patients end up with chronic dizziness. So chronic dizziness is one of my areas of interest, chronic dizziness. Why does it happen? Who is more at risk of developing chronic dizziness and what can we do about it? You know, dizziness is not a big area of research. There are not a lot of people or centers doing it in the world. If you go to the big biannual BRANI meeting, where basically everyone who’s who does vestibular and dizziness research goes, it is only like 300 people, for the whole world so it is not a lot of people. It is challenging to get funding, despite it being such a common affliction of everybody, nobody seems to want to fund it. So really it has been challenging, but definitely we have been putting some good work out in the area of chronic dizziness. I work with some of my colleagues on hearing research as well, sudden hearing loss and things like that. I am actually pretty interested in BPPV as well, Benign positional vertigo because that is super common and surprisingly poorly treated. I actually have an innovation project going right now, and this really got pushed ahead because of virtual care, to try and use some sort of digital AI solution, to diagnose patients with BPPV. You know how you go on the Roger’s home page, you get the chat bot, or websites these days you are talking to a chat bot, So we are trying to make a chat bot or something where we can diagnose and give the treatment that they need without having to go to the Emergency or whatever. So that is kind of a big project that we are hoping to start right now. As well as another trial we are going with BPPV. So those are my two big areas right now general work or kind of projects on chronic dizziness as well as on BPPV. 

Hannah: 

That is really interesting how because you are seeing such a large volume of dizziness patients you are creating a database that can help streamline research.

Dr. Tse:

Yeah, I know there are some colleagues of mine that have started recently or after I started with very particular specialist interests, and like first thing you have to do before seeing all these patients is like start collecting them. Start from the beginning even if it is on an excel spreadsheet, start with something because then you can, later on that can start to bear fruit but if you don’t start it you will never get it. 

Hannah:

Great, Finally, we wanted to ask if you have any advice for medical students, in general and those interested in otolaryngology?

Dr. Tse: 

I give the advice to all students that ask about the common question: basically how did you decide you wanted to do X and not do X. My advice is that you got to choose something that you can deal with, the bad stuff everyday, the bad parts of it. Because most of the time its good stuff, sometimes you have to deal with the bad stuff or the really common things. If you don’t think you can deal with the bad parts or common parts of the specialty then that is probably not for you, because that will probably be something you have to deal with a lot, before you get to the more interesting stuff. Medicine is like 90% routine and 10% craziness. So if you can’t deal with the routine, you are not going to enjoy yourself. 

Thee other advice is people always ask me, “well what would you suggest in terms of picking this residency versus thiis residency or that residency, you know which university. To me I give the very, I don’t know if it is just my approach to it coming from an area where I didn’t have too much choice, if you had to pick probably you are going to be just as good as specialist or doctor from any residency, so you should pick the one where you want to live for 5 years. That could be because people are there, family or you just want to check it out or move away from family, I don’t know, but just pick somewhere where you think you could live for 5 years, or maybe for longer because a lot of people end up staying where they do residency whether they intend to do that in the beginning or not, so that is how I tell people to choose where to go. In terms of ENT, if you want to do ENT the best thing to do is try and see lots of different parts of ENT. A lot of universities still don’t have any mandatory ENT, in Ottawa we have 1 week. But your experience of ENT even in Ottawa will depend on which hospital you go to that week, if you end up in the OR or clinic, who you work with. It can be extremely variable even in one medical school. Especially if you don’t have ENT exposure, you really don’t know. I think if there is any interest at all, you just have to try hard to get some exposure to different parts of it and see if you really like it. Of course, COVID makes that really difficult these days and I feel bad for students since COVID. I don’t even know how, I can only imagine how bad it has been. But now things are opening up a little bit, just try and experience different parts and see if it is for you. And if you do want to get into ENT, it is fairly competitive so you do need to get around and see people and go to different places. Show yourself, work hard, and yeah it should work out.  

Hannah:

That is really great advice, particularly for students going through the carms process now and thinking about where they can do residency and what is the best fit. 

Dr. Tse:

Yeah, I think if you go somewhere, and you don’t like the people you don’t want to go there for residency, no matter how reputable or unreputable, or whatever, or how much surgery they do or how little, everybody is going to end up fine at the end right. Despite what everyone says about this program being more surgical or that program being less surgical everybody is perfectly fine at the end. So can you work with these people for 5 years, can you live there for 5 years, that is the important thing because there is more to life than work. That is what really makes residency good, is the people you work with and where you are living. Because you will learn your surgery, you will learn your facts, everybody learns that stuff. So there is more to live than learning things. 

Hannah: 

That is a really good point as well. Thank you so much Dr. Tse for taking the time to talk with us about your journey and how you focused your practice and research. And Thank you to the listeners who tuned in, we hope to see you back for our next episode.