Welcome to episode four of The Oto Approach! Listen for an inside look into the subspecialty of pediatric otolaryngology. Our guest speaker Dr. Liane Johnson is a pediatric otolaryngologist at the IWK Health Center in Halifax, Nova Scotia. She completed a Bachelor of Science at Western University followed by her Medical Degree at McGill University, then completing Otolaryngology - Head and Neck Surgery residency at Dalhousie University, followed by an accredited fellowship in pediatric airway surgery at the Cincinnati Children’s Medical Center.

Show Notes

Aileen: Hey everyone, and welcome back to The Oto Approach, a podcast created by medical students for medical students to teach you about all things otolaryngology. I'm your host Aileen, today we are joined by Dr. Liane Johnson who has worked at the IWK Health Center in Halifax, Nova Scotia as a pediatric otolaryngologist since 2003. She spent 17 years getting there beginning with a Bachelor of Science at Western University followed by a medical degree at McGill University and then moving further east for residency training at Dalhousie University beginning in anaesthesia, but then changing to otolaryngology - head and neck surgery, ultimately sub specializing in pediatric airway surgery at Cincinnati Children's Medical Center.

As an academic surgeon her responsibilities include teaching medical students and residents in formal lectures, but mostly through interactive teaching in clinic and operating room settings. Outside of clinic and teaching duties, she has also been involved in educational duties at the Royal College of Physicians and Surgeons of Canada and simulation-based airway training locally throughout Canada and the USA. These experiences have allowed her to contribute her expertise in textbook chapters and clinically based research papers as well. Outside of the medical world Dr. Johnson is also a mom of four kids, she has a dog and two cats, and her husband is a mechanical engineer, home inspector and vineyard manager. Dr. Johnson and her husband just retired from more than 20 years of competitive Ultimate Frisbee playing at the national and international level. They are now focusing on vineyard development and it is their future retirement plan. Dr. Johnson's motto is anything is possible. 

Okay, so getting right into it we were wondering if you would mind telling listeners about the training that's required to become a pediatric otolaryngologist.

Dr. Johnson: Pediatric otolaryngology is a specialty that you do after you finish your otolaryngology residency, which is typically a five year residency. Currently anybody coming into otolaryngology will be in the Royal College’s new program, so every site across Canada has a CBD program, which is Competence By Design. So it is very greatly involved with your faculty one-on-one, lots of daily feedback, and you have tasks to complete. So once you have completed your five years, of which you will probably do a minimum of 6 months of pediatric training in your residency, you can choose to do a fellowship. There are different fellowships across North America, Australia, there are some in France, United Kingdom so there is lots of options. There are accredited fellowships which tend to be a two year fellowship, but many are 1 year. So I did an accredited two year fellowship in Cincinnati Ohio at the Cincinnati Children’s Hospital. Which is an absolutely fantastic fellowship and great experience. It is mostly airway surgery, but it also covered all facets of pediatric otolaryngology. The only other accredited fellowship outside of Canada and the US might be Great Ormond Street (Children’s hospital in the UK). 

Aileen: Thank you so much for touching on what is required to become a pediatric otolaryngologist. We were also wondering if you could touch on what are the main differences between pediatric versus adult otolaryngology.

Dr. Johnson: That is a really good question, it's more than just little adults, it’s vastly different as you will know when you do your pediatric rotation, the physiology, kids can tolerate a little bit more unwellness as you wish before they fall off the cliff, but when they hit the limit of their physiology they fall hard and fast, but they do tend to recover. 

The pediatric problems are much different, we have many congenital problems to deal with, many syndromic problems to deal with. Actually, the adult world is evolving as well because many of these children now are surviving outside of what were the norms in the past, which often they didn’t graduate or transition to out of hospital. So, many things that we see, will now be seen also in the adult realm. But we tend to deal with it on the front end, establish multidisciplinary care for the patients, often the more complicated ones, so they can have a more all encompassing transition and continuing care. So it is different problem sets, and because I primarily do airway, anything that is complex from an airway standpoint I deal with a lot of neonates, some congenital issues. Now being a pediatric ENT you need to have good airway training for not just what I do, which is airway surgery, pediatric otolaryngology training will include airway training, simply because it's very important for foreign body retrievals, airway assessment, helping out the NICU with the different issues they have with their preterm or complex newborns. So it is a very, I like it, it is a very dynamic practice. 

Many generalists will also do pediatrics, there's a lot of the bread-and-butter which is tubes and tonsils which really crosses over into general otolaryngology. When you’re a subspecialist you will start adding the more complex patients, one’s with syndromes or other complex issues that need to be managed at the tertiary care center. Actually, quite a lot of pediatric otolaryngology in the otherwise healthy child can be done in peripheral hospitals, there are different rules depending on the hospital and anesthesias comfort with general anesthesia for certain age groups, so in Nova Scotia many hospitals will do tubes in kids two and over, but won’t do tonsils unless the children are five or over in the peripheral hospital. So even though I am tertiary and quaternary care, I still do a lot of otherwise healthy kids who just have an issue that needs to be addressed. 

Aileen: Thank you so much, I think that provides our listeners with a good explanation of the differences between pediatric and adult otolaryngology. We were also wondering if you could tell us a bit about the most common cases you encounter in your practice of pediatric otolaryngology. 

Dr. Johnson: Well this is a really interesting time to be asking me that question. Because this is the first time in over 15 years where in the winter the months we would see hundreds of children with recurrent ear infections, this brings along lots of social issues for the families, for the children, lots of repeated antibiotics, lots of doctors visits, lots of sick time for the parents. It is a very stressful time for these families. Most of these children, with this particular problem and when it starts are under two, often they just started daycare so there is a whole host of issues here. Now that we are in this pandemic situation, there is a bit of a silver lining, and I do tend to be a bit of a more positive person with my outcome, but this is shockingly amazing, I have to say I am not even seeing a tenth of what we would normally see. So the children are just healthier right now, because we are all masked up, there haven’t been any cases of the flu or RSV this winter.

It’s really been an unique situation. And as an offshoot of that, there’s been a huge change in the demographic of what we are seeing. We are seeing a lot more nosebleeds than we are ear infections. But ear infections, especially in the 2 and under or persistent middle ear fluid, which impacts hearing and potentially speech, school learning and things like that, we see in the slightly older children, 5, 6, 7 sometimes. As an offshoot of that, children older than 2 can also have upper airway obstruction, so large adenoids, potentially large adenoids and tonsils which are contributing to the ear issues. So that is probably the biggest bread and butter. I think generalist, can also, if you're putting tubes in the ear, it would be really important to know how to fix that, if there was a residual hole. So doing tympanoplasty, which is patching the eardrum, would also be under the purview of a generalist, but we also do that as well. What other things? Epistaxis, so Nosebleeds are very common in kids. In every clinic, I feel like I’m doing 2 or 3. Currently, these are not seen in hundreds of kids with ear infections. So It's been a very interesting switch. I’m a little bit excited to see what’s going to happen coming into the future. Does this mean that there will be hundreds of kids who never got tubes that should have? It will be very interesting to see for the demographic of our practice in the next 5 years. 

Alieen: Wow what an interesting point to bring up about how your practice has changed throughout the pandemic and how you predict it might change in the future as well. We were also wondering if you could speak a little bit about who you collaborate the most with in your practice?

Dr. Johnson: Well, anesthesia always. So if it’s someone going to the OR, I’ll often run up and talk to a colleague and we will review the more challenging cases, or at least make a plan or see if they have any concerns or want any other investigation, which isn’t very common but it’s just good to have a conversation. Respirology, Gastroenterology are 2 that we collaborate with frequently. I also do all the thyroid surgeries, so I work very closely with endocrinology. And Radiology is at the basis of everything that we do so there’s lots of collaboration. And really, I’m in a pediatric hospital, so all facets of care fall with my pediatric colleagues, both in the emergency department as well as those in the clinic. So it’s variable, there isn’t a consistent multidisciplinary team. It’s nice that most of the divisions are fairly small. At one point or another, I would have encountered most of the other physicians. So you can just pick up the phone. Sometimes, even just trouble-shoot a patient without an official consult. So it's really nice collaborative care, at least from my standpoint at this hospital. Pretty much all facets, genetics is greatly involved there, greatly overwhelmed by the demand there currently. They don’t tend to work together in clinics, but they have a huge impact on where we go from here with certain patients and the care plan. 

Alieen: Absolutely, Thank you so much. We were also wondering if you could tell us what the most challenging parts of your job are and also what are some of the most rewarding part of your job 

Dr. Johnson: I think it’s just the layers of involvement that you need in certain patients, it’s really listening to the patients and trying to make sure the care is delivered in what they are seeking and what they need. I’m also a strong believer that I’m not here to fix things, that I’m here to, the body is really smart and I’m here to facilitate. 

And so a lot of the surgeries that I do, like tonsils, adenoids, and tubes, we just kick start the body and give it the means by which it can slowly resolve the chronic inflammation and things like that. From an airways standpoint, I am more of a fixer, but I have to be very cautious and conscientious, that I’m not there to go make these big huge strides again, setting expectations with the family, being very patient. We are definitely in a society where we want the fix now. And so I think maybe that is sometimes the biggest challenge, is making sure that you are able to communicate clearly, have those open conversations, and it’s not one conversation. I’ve realized it’s really challenging to explain what we do sometimes in a complex area, especially when I try to explain to families the airway surgery. It’s such a visual thing for me, yet in the day to day life we don’t go around seeing our airway. So when I start to try and explain vocal cords and subglottis and trachea, they aren’t things that we see in the day to day. So it definitely takes time, patience, repeated conversations. Families normally, it’s really amazing actually, you see them just relinquish trust and are on board with the treatment plan and the focus goes from let's fix this now to yes it’s all for my child, and we are going to do the best we can. You set long term goals and anytime you achieve those goals a little ahead of the date, that’s a celebration. As opposed to, saying “Oh maybe next time it will be ready,” and it’s not and you go through disappointment. I’m very cautious about setting some long term plans with families, really engaging them. I have a fantastic airway nurse, who helps do some of the teaching, although there’s a whole teaching room setup for tracheostomy patients. But working with Tracey, who closely will stay in touch with families and if there's more information that needed, I will just jump in on a different phone call or conversation with the family. So we have a really nice dynamic that way. And I didn’t mention in the last question, but whenever we do airway surgeries, one of my colleagues from the adult hospital, he comes and operates with me. So we have created a little airway team, because he doesn’t have a lot of airway surgery experience but he does have a lot with voice. So there is a significant overlap in what we do. So that way, when there’s an airway surgery that needs to be done with adults, I go over there to help with the case as well. So we got our little, mini airway team. And most of my patients, once they have graduated from an airway issue, will have some voice issues to contend with, and so they will go see Dr. Brown. So we have this nice working relationship, where our patients are cared for by this mini team of ours. 

There’s a really interesting multidisciplinary care team that was started when I was a fellow in Cincinnati called the Aerodigestive center. And unfortunately in Nova Scotia, we don’t have multidisciplinary care codes and although I'm not a fee-for-service surgeon, I'm basically salaried on an academic funding plan. They still don't allow that, so we are doing this dualized care for the patients, we are doing maybe two surgeons or Physicians, but not these multidisciplinary physicians. So these airway digestive clinics, not only was it otolaryngology, you had respirology, gastroenterology, pediatrics, allergy, sleep medicine, I’m missing something- there’s probably dentistry and craniofacial. So just a really big encompassed group to deal with these more complex patients with multi layers of airway obstruction or issues. It really provides optimized care for these more complex patients. So I see things are going this way, I think it’s a little challenging to digest for the system the way it’s set up. But it’s slowly changing, I think, as well the pediatric hospital, from my standpoint- here’s my bias- is that I really think people are here for the kids. So if I ask, and I’m not hesitant to ask, it’s amazing what people will do to come together. So it really is possible to still collaborate, even if your not all in the same room at the same time. 

Thank you so much for speaking about that. I know a lot of our listeners are interested in who they would be collaborating with should they undertake an otolaryngology career. We were also wondering along the lines of collaboration, if you could talk a little bit about your experiences with teaching and research in the field.

From a teaching standpoint, when I first started in practice, I started doing the weekly exams for the residents, which is really just a means of checking in and seeing how you're doing from a knowledge based standpoint. And I don't really have an education background, but I was just really interested in it. And from there slowly over time things have evolved, I started volunteering with the Royal College, at the examination committee at the time- examination board, it keeps changing its name. So creating exams. So from this, I started learning a lot more. I started this simulation sessions working in collaboration with anesthesia and nursing. So we do this into interdisciplinary simulation, usually it's an airway simulation. We have this small mannequin mimicking a 1 year old that's hooked up to monitors. So they work collaboratively, to help really train anaesthesia residents, otolaryngology residents, and it's a really good brush up for our nursing staff, Because they are there consistently and they are cases that aren’t done frequently but they are high risk, or high stakes cases. So from an education standpoint, I really feel that I'm slowly evolving my interests, and I'm really interested in, actually I know it's not education in a pure sense, I'm really interested in starting a mentorship program, initially for the women faculty in the department of surgery. And seeing how we can train ourselves to be future mentors/educators for residents coming through, and eventually trickle down to the med school. Because I really think if we don’t get buy in from the upper echelons, it's easy to get buy in when you are in- I would have signed up for anything in med school. Right so, I think it's really- you kind of have to start at the beginning, make sure that everyone is supporting each other, that they have a unified goal, that they have an understanding of what their role is. And so that we can start expanding that and really increasing interest. I think that’s where I’m- I know it’s not really pure education, but it’s definitely my interest from this standpoint, it’s just broadening the spectrum of getting the knowledge of our specialty out there, increasing interest. But not just- It doesn’t have to be just Otolaryngology, really any surgical subspeciality for women. I think people shy away, I really want to ensure that people see somebody like them that’s doing a role that they could see themselves potentially doing. And just increasing the choices, or the visible choices perhaps. 

So not really pure education, but I think it will benefit in the future. And definitely I want to continue with stimulation. I think there’s a lot we can do, especially in this new CBD curriculum, through the Royal College, in terms of there are fewer training hours and all of these other potential restrictions. This way it’s like doing simulation training for airplane pilots. So you put in the hours, and it might not be a true patient, but man, your physiology feels like you're doing a real patient. So, your heart is racing, your palms are sweating, you are feeling stressed about making decisions. So I think it is very practical. I think it is a significant adjunct to the day-to-day with no harm to the patient nor to yourself. 

The research that I do tends to be airway oriented or really based on clinical improvements, so something that will help me provide better care for my patients. I am a part of a few across Canada, research groups, we are looking at laryngeal papilloma in children. So we have been collecting data for 15 years and every 5 years we continue to collect data, and we are hoping to see that the Gardasil vaccine leads to a reduction in incidence, and perhaps also reduction of severity of disease, because it's more aggressive in children than it is in adults. I'm also part of another group that is a North American group, which crosses over to the US where the primary researcher is. It's also an offshoot of this papilloma looking at an adjunctive treatment. So there's all these biologic modifier drugs that are coming out, monoclonal antibody drugs. It’s really changing medicine. You guys are starting at a very exciting time, where for many diseases, and I won't call them orphan diseases necessarily, but not as common diseases, but again high impact for the family and patient who have them. There's a lot of potential other treatments now. So over the last 5 to 10 years things have started to shake up a little bit, they are more exciting, and I’m really excited to see how this might slowly put me out of business. Some of these patients might not need surgery and we could improve their situation, their infection, if we are talking about papilloma, with systemic treatment. 

Alieen: That's so interesting, thank you so much for speaking about that. The last thing we wanted to ask you was what advice would you give to yourself as a medical student or when you were just starting out in the field of otolaryngology? 

Dr. Johnson: Well I didn't mention this, but I didn't start off residency in otolaryngology. I started off in anaesthesia. So I did two years in anaesthesia. So as a med student I had no idea what otolaryngology was. I did med school at McGill, we did a two-week block that consisted of otolaryngology and ophthalmology. I feel like I've retained no ophthalmology, because if I see a consult from an ophthalmologist I have no idea what they are talking about, I can make out left eye and right eye but other than that that's it. I semi joke but not really. So I really didn't have a lot of exposure, and I think and I am hoping that the current design of the med school curriculum is such that you have a little bit better exposure, perhaps even better support and mentorship. I don't want to put down my med school because I really loved every second of it, but It didn't have a lot of one-on-one with staff. So it was very hierarchical, so oftentimes it was the PGY-2 that was giving the med student the, you know leading us by the hand and showing us what to do. So we didn’t really have a good sense of things. But in anaesthesia, It was one on one with staff. That, I feel like, was one of my only experiences having that direct contact with staff and getting lots of positive feedback. I felt like “Oh this is what I should do.” So when I started residency, It is very exciting, and I liked the manual techniques and loved the airway- that was my passion from the beginning. But I quickly realized that at 4:00 in the morning, instead of monitoring my patients physiology, which is still an incredibly important job, but I actually realized I wanted to be doing more. And it did take me a while because I wanted to ensure that it wasn't just a flight of fancy and I really wanted to do more from a surgical standpoint. So I didn't switch until after I had completed two years of residency. I had to go through an interview process, because luck of timing there was a spot that opened up, actually at the same university. And of the candidates I was luckily chosen, I use the word luck, but sometimes it's timing and your background. And from my standpoint I do feel incredibly lucky that what a wonderful residency I had and I was able to combine my love of anesthesia with otolaryngology and with airway, and do a fellowship in airway surgery. 

It really has been a unique path, and so I just hope that from a med school standpoint, there is a means of getting a little bit more mentorship, a little bit more one-on-one, trying to explore who you are but it’s so hard in medicine when we are still getting to know ourselves, we know so little about the globality of all of the different specialities and facets for patient care when your starting in med school. Everything’s new, the language is new, everything is new, so I feel like it is a hard time to make a decision, you really are evolving as a person, so that adds a second challenge. And oftentimes you feel like you love everything, so it’s really hard to be able to be honest with yourself and make a decision. Some mentorship is helpful, lots of observer time is also helpful, and really not being afraid. I think that was the big thing for me. Somehow in my head I was telling myself, “I didn’t want to lead the life of a surgeon,” and I wanted to still be able to have a life. And somehow ultimately I was like I’m having the life of a surgeon with anesthesia, with just different responsibilities. 

I think the other thing to from my standpoint, I hadn’t realized that about myself, that I really liked the patient interaction. In anesthesia, you still get patient interaction, it’s very different, it’s very intense, it’s very brief. And you often don’t know what happens to them after, very similar to emergency medicine actually. And I realized from my standpoint, that was a really important thing for myself, for my growth, as a clinician, for my happiness as a human, I had to have that ability to get to know patients. From an otolaryngology standpoint, sometimes we don’t see patients, either you meet them once in clinic, you operate on them and we do a phone call follow up, say for example for tonsillectomy patients. So I don’t have a deep relationship for them, but I definitely make sure that that encounter, that 20ish minute encounter the first time is a good one and resupported by the next encounter before the surgery. So it’s a very unique thing. So there are little facets that we don’t think of, what’s important for us for our personality, because we are still developing. It’s hard. So having a good mentor might help you look at the things that are important to you from a person and what fits with your personality standpoint. And I think you can be happy with more than just one choice, but I think it is important to dig deep a little bit and try to figure that out.         

Alieen: Yes absolutely and that's one of the main goals of this podcast is to help expose medical students to otolaryngology, so that they can decide if it's something that they're interested in. Thank you so much Dr. Johnson for that amazing interview and for sharing your knowledge and experiences with us. Thank you to listeners for tuning in today and we hope that you'll be back for our next episode. 

Thank you so much for listening to our podcast!

We would like to extend our sincerest thanks to the Saint John Regional Hospital Department of Surgery within the Horizon Health Network for their generous support. Please head to our website at www.theotoapproach.com for our show notes, and to sign up for our newsletter to stay up to date with our latest episodes.