Sleep Surgery and Medicine: An Inside Look with Dr. Josie Xu

Join us for our 17th episode with Dr. Josie Xu, a board certified otolaryngologist with a fellowship in sleep medicine and surgery. You won’t want to miss out on learning about this exciting and rapidly-developing sub-specialty!

Show Notes

Huaqi Li: 

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, Huaqi Li, and today we’re going to be joined by the lovely Dr. Josie Xu! 

Dr. Josie Xu is an otolaryngology-head and neck surgeon currently practicing at North York General and Michael Garron Hospital in Toronto. She completed her Bachelor's of Health Science from McMaster University and then her MD from Queen's University. She did her residency in Otolaryngology-Head and Neck Surgery at the University of Toronto where she worked on research related to medical education, patient education and mobile health technology. She most recently completed her fellowship in Sleep Surgery and Sleep Medicine at the University of Southern California in Los Angeles, California.

Thank you so much for joining us today Dr. Xu, super excited to hear about your journey thus far. So why dont we go ahead and get started with our first question.

Could you please tell us a little bit about yourself?

Dr. Xu: Well Huaqi Li, thank you so much for the invitation. Absolutely delighted to be here on the podcast to share a little about what it has been like to get here so far. You have covered most of my educational background. And so, I have been doing school all around Ontario, went to California and came back. I was born in Halifax, and lived in Toronto for most of my life. In undergrad I did a lot of maybe non-medical things, like graphic design, and running some events and orientation week and all that kind of stuff all through medical school too. And then in residency it got pretty busy, so hobbies were on hold for a little bit of time. But now that I have started to become a staff physician, I am rediscovering my hobbies. My partner and I have moved out to the east end, we are really enjoying it here, doing outdoor activities, doing some beach volleyball and spending lots of time with friends and family, and of course work and everything in between as well. 

Huaqi Li: That sounds lovely. Great to hear that you have some time to rediscover some of your older hobbies. In terms of what drew you to the speciality in the first place, can you tell us a little bit about that? 

Dr. Xu: Absolutely, so when I was in medical school I think I realized that I was drawn more to things that had more visual diagnosis, or doing tactile things with my hands, as opposed to some of the other specialties where maybe it was more, you know, interpreting blood work, and more let’s call it cerebral problem solving, like on you know House. Rather than, I kind of like looking at something and diagnosing it and seeing what we can do to solve that problem. So I was drawn definitely toward surgery at first. I definitely also liked how in surgery there were certain problems where you could diagnose it, you could offer a solution, and then you could move on, and hopefully the patient would do well. And although you know chronic patient care is extremely important and very valued and needed, I just felt that my personality and my skill set was better suited for something maybe in surgery. So, from there I decided to think about all the different subspecialties, and whether they might be something that I would like. So I really just started shadowing in all the different surgical subspecialties to see which one was a good fit and which one made the most sense to me, which group I seemed to click with the most. In the end when I explored more about otolaryngology head and neck surgery there was so much about it that I liked and a lot of it had to do with the breadth of the speciality. I really enjoyed how I could see newborn babies but also elderly patients, and the adults in the middle. I really liked how the procedures could be something as mundane as cleaning ear wax, which can bring so much joy to someone to something that is incredibly life threatening like the airway cases or super long free flap cases, which can take all day, very technically complicated and very challenging, sick patients. I really like that breadth. The breadth of subspecialties is really something else. I mean a lot of people don’t realize that within our small speciality we have so many subspecialties. You guys have done a really great job at highlighting a lot of those in the podcast so far, which is wonderful. But otology and neuro-otology is so different from head and neck surgery which is so different from laryngology care of the professional voice, which is so different from pediatric otolaryngology. I think there are so many different facets to the speciality that are amazing. I really like how we make such a difference in patients' lives, especially with regards to their senses and their quality of life. So to be able to support someone with changes in their hearing or their smell or ability to have a sound night sleep, you know all of those things are maybe not life threatening but can make such a big difference in quality of life and people’s ability to do and be themselves. So when I saw the difference that some of those treatments or medical procedures could make when I was a medical student, I thought wow this is a pretty special and amazing speciality. I loved that there was medicine, that there was surgery and you know I just stuck with it. And at the end of the day it was also the people that I met within the speciality just seemed really welcoming and really open and people that I felt like I could click with and I just jumped feet first and here we are. 

Huaqi Li: That’s amazing. The speciality definitely has so much breadth and I have come to appreciate it over the last few months or so. You send that you kind of got into it through shadowing was your first exposure, going into clerkship were you kind of set on otolaryngology at that point or were you still thinking about different specialities. 

Dr. Xu: No, definitely not set at all. I think I was leaning towards surgery at first but I tried really hard to keep an open mind and I was very open to a parallel plan in family medicine. Although family medicine is extremely different practice, extremely different day to day, extremely different patient population in some ways, I thought that I could be happy, so I applied to both and kind of pushed on forward. In the end I just saw where my interviews were, I thought really hard about the difference in specialties, and I ended up ranking in my order of preference. And so I really strongly believe that people could probably do multiple specialities, so I think it is really important for people to keep an open mind and it is more than just what you see in clerkship. So no I was definitely not confirmed or set on it at the beginning of clerkship. I really only started thinking about it at the end of second year. So you know, the road is long. 

Huaqi Li: That’s definitely comforting for us incoming clerks with all these different specialties to think about. As you said, otolaryngology has a lot of different subspecialties and you recently completed your fellowship in sleep surgery. How did you decide to pursue that specifically?

Dr. Xu: Yeah, that is a great question. I think so many people come to a decision on fellowship in so many different ways. I thought about it maybe in a slightly backwards way to maybe some of the way that other people thought about it. I definitely tried to envision where I saw myself, in terms of where I wanted to practice and what kind of practice I wanted to have. I figured I would probably be the most happy in a community based practice, but with some sort of subspeciality, where I could either have an area of expertise in the academic world or in education or in research. 

So then I went on to think about what kinds of subspecialities were needed in certain communities, maybe what was up and coming, and what just needed more exposure or more visibility. So we do a lot of procedures that are for obstructive sleep apnea. So sleep surgery is primarily for surgical treatments for obstructive sleep apnea, which is when people have pauses or blockages in their breathing during sleep. That could be tonsillectomies, that could be septoplasties, and adenoidectomies in kids. And so it is something that we already see a lot of the time, and those are the main surgeries that we offer. But really, obstructive sleep apnea is blockage in the upper airway, anywhere from the nose down to the larynx. And that could include the epiglottis, that could include the lateral pharyngeal walls, it could include the tongue. And to me, it was kind of crazy that there weren’t that many otolaryngologists involved in the care of obstructive sleep apnea patients, when really we are the upper airway experts. And we are the upper airway experts in medicine and in surgery. And so sleep medicine has so many different subspecialities involved in it. So sleep medicine physicians are often respirologists, neurologists, psychiatrists, or even anesthesiologists and there are also dentists and oral surgeons that are involved, even psychologists that are involved in sleep health. But we are the upper airway surgeons, so this is truly- I mean, obstruction of the upper airway is the definition of the problem, and so I really wanted to learn more about it and how we could fit into that clinical paradigm. And so I just started to learn more about what people were doing in other areas of the world, and I realized that surgical sleep apnea care in Canada is a little bit behind. Even though it is estimated that 30% of the population in Canada is at high risk for obstructive sleep apnea, 30% let’s think about that for a second, there is a massive underdiagnosis rate, probably 70-80%. And so not only is it a recognition problem, but it is a diagnosis problem, and it is a treatment problem. There are other countries like Taiwan and Singapore that have done more work in this area and in the U.S people have pursued different types of treatment, and so I started to reach out to experts in their field in these different areas to see what kind of things they do, and is that something that might be feasible in Canada. And so when I started to think about it more and reach out to them as a resident I did electives with some of these surgeons, most notably in California with multiple surgeons and Taiwan and Singapore, and it was amazing to see different medical environment, but also a completely different way of thinking about a very similar problem to the patients we have here. So I really liked it and again I jumped forward and I talked to a lot of mentors, about you know what is the role of subspecialized, you know, sleep surgery in Canada and everyone I talked to said “it is underserviced, it is under diagnosed and we definitely need more help in this area.” So what can I do to learn more and bring things back. And that was my thought process about thinking about subspecialty. 

I was really lucky to go to my fellowship in sleep surgery at the University of Southern California. I worked with this amazing surgeon, Dr. Eric Cusarian, who really is a pioneer in the field of sleep surgery for decades. He has been thinking about these clinical problems, treating these patients, trying new surgeries, putting out research, you know a real leader in the community, in the small sleep surgery community. He very graciously offered me a training position in COVID no less. And so I went during COVID. It was the most wonderful experience and it is so wonderful to be able to focus all of your attention on something for a whole year. You realize that there is so much more to it, you can always learn more, there is always more to discover, more to research, more to work on and that was my fellowship experience. I am excited to bring some of those ideas back to Toronto to participate and provide my insight wherever I can. 

Huaqi Li: That is so great. Thank you for the insight. It is definitely interesting to hear about the international experience, and how different countries might do things differently, outside of Canada. So now that you are back in Canada, what does a day in the life look like for you?

Dr. Xu: Absolutely, so my days are mostly split into either clinic days or OR days. So clinic days I would say are mostly similar to other people’s clinic days. My clinic days are at a community office that I share with some other partners. I probably see patients from between 8-9 o’clock to about 4-5 o’clock, hopefully a little lunch break in between, if I am on time. We see a whole mix of patients, children, adults you know seniors, some of them get audiograms beforehand, some of them are just going to be histories and physicals and counseling appointments. Some of them might be minor procedures, like putting in a tube in the ear or an intratympanic injection, something like that. We will have some other specialized clinics in the hospital, where we will do minor procedures, like biopsies in the mouth or on the skin, or neck mass. There is also a lot of paperwork, that is sprinkled in there, and hopefully you can get it done during the day that would be great, but once in a while you bring it home with you and you have to finish extra notes, or referral letters or following up on blood work or imaging, planning for OR’s. So there is definitely a lot of background work. 

My split is that I see a lot of general otolaryngology patients in addition to sleep apnea patients, and so those kind of get sprinkled throughout my day. The OR days are kind of standard, community OR days, starting around 7:30 in the morning going to around 3:30 in the afternoon. Our pediatric cases are quite fast, so it is a lot of quick surgeries, talking to a lot of family members, bringing them to PACU, rinse and repeat. It is a lot of fun. Some of our cases are longer, so you turn on some music, catch up with your assist or the other OR staff. So it is a ton of fun in the operating room. So I think that a lot of people end up liking ENT because they are able to do surgery and the OR is a nice reprieve from the day to day clinic life for sure. 

Of course you can’t forget about the on-call responsibility, so you share that with you other colleagues, whether it is being on call during the daytime or in the evenings and weekends, we all split that. It is a mix of phone calls, coming in for some semi-urgent consults, or doing emergency operations where needed. So, it is definitely less busy than residency at least for me so far, it is a lot of fun and there are always lots of unexpected things that happen everyday. 

Huaqi Li: That definitely sounds like an adventure, maybe a little bit of a change in pace from residency life for sure. Related to that question, as a relatively recent resident, what were some of the challenges or surprises that you faced since becoming staff and/or in your career thus far?

Dr. Xu: So I think that all transitions can be very challenging and all transitions have that change in responsibility. The transition in becoming an attending staff is that of course you are responsible for the patient and the buck stops with you. When people ask for advice or a surgical consultation, you know, you are the person people are coming to. And that level of responsibility, even though in training you learn exactly what you need to do, exactly what you need to say, I think that level of responsibility still feels different somehow. And there is definitely an element of imposter syndrome at different stages of transitions. I certainly have gone through it in different levels of training and now as an attending physician, and when you are finally an attending physician you think that maybe it will go away. It definitely does not go away. People look at you for advice, for expertise, for guidance, and for a second perhaps you think “why are they looking to me for advice? I just started.” Part of the learning process is trusting yourself, trusting your training, trusting your knowledge, trusting the experiences we did have through training, and knowing that you are actually capable and you have the skills and knowledge to help the patient. I think that in Canada we are really lucky to have amazing residency programs with very supportive staff and a great educational framework to prepare us very well to become attending physicians. But regardless, that transition and being ultimately responsible and trusting yourself and believing in yourself can be a challenging one. I would say that is still an ongoing process as part of being a new staff. I think in residency, we see challenging things like complications, but sometimes you don’t see them in a long term way, in a longitudinal way that you may see as an attending physician. As a resident or as a medical student you are constantly rotating through different rotations and you might be with patients for a certain period of time, but you may not see them for more than a 3 month chunk of time, or maybe a 6 month chunk of time. Similarly seeing complications that are ultimately your responsibility can be very challenging. This happens in all different types of medicine and surgery of course, but in surgery there is a certain element of the acuity of the complications, the gravity of the consequences of the complications that can be quite difficult depending on the person emotionally and depending on how much you take that home with you. It is not an easy thing to process yourself. I am very lucky to have supportive mentors and colleagues to bounce ideas off of and to learn from. I think those are some of the main challenges that I have had in my first couple of months of practice. But the ultimate amazing thing is that you never stop learning, you never stop having mentorship with the people around you. After residency the camaraderie and the learning doesn’t stop. I am so lucky to have senior colleagues and peers around me that I can turn to advice or emotional support for when something does not go the way you expect it to. Otolaryngology is a small community and everybody knows each other, you know we all have our areas of expertise and everyone is willing to support each other and lend an ear, because everyone has been there at different levels of training. So despite the difficult challenges during this transition, we are really lucky to have this amazing supportive community around us. So that is one thing we know will always sort of take us forward. 

Huaqi Li: Definitely support is so important in many different aspects of people’s careers. Do you have any advice for medical students in general but also for those interested in Otolaryngology?

Dr Xu: Absolutely. So the first thing is, enjoy medical school as much as you can. It is short, it is difficult, but hopefully you only do it once. It really is a magical time with really quite phenomenal people. So go to class. So to the social events. Get to know your colleagues. It is really difficult in an era where you have a lot of virtual classes and virtual meetings and things like that. It is so difficult, but these colleagues and classmates are really going to be your colleagues for life. You are sharing an amazing time in your life together. You are always going to see people in the hospitals moving forward that you went to medical school with. I am really so very thankful for my friendships from medical school moving forward. Don’t dwell too much on the next steps and really try to enjoy medical school as much as you can, because it is a really carefree and wonderful time relative to some of the challenges going forward. 

I think when you are thinking about choosing a speciality it is a really important decision and as I mentioned before, I think it is really important to keep an open mind. It is really challenging when people come into a learning situation or rotation thinking I am going to absolutely do this and definitely not that. The medical students that keep an open mind and try their hardest on every subspecialty are the ones that often perform the best and the ones that become better, more rounded physicians overall because they have spent the time and mental energy to learn as much as they can. And also you never know, when you go on a rotation, what might peak your interest, or what might surprise you in clerkship or residency, if you think you would be better suited for another speciality. I think it is really important when thinking about a speciality to not just love the content. It is great when you love the content, when you live and breathe the content. I had this friend in undergrad and medical school, she just loved placentas so much. She couldn’t imagine doing anything other than obstetrics and gynecology, which is wonderful. Not everyone has such a strong inclination towards a specific topic, hopefully you like it a lot. But the other thing really is thinking what is life like as an X, what is outside life like as an X specialist.  I think podcasts like this are really wonderful to try and see and get a better grasp on what people’s lives are really like, because it is definitely not always like the chief at academic centers. The average otolaryngologist is not a program director at a residency training program. And so, what does the average otolaryngologist do? What kind of cases are they doing? How much overnight work are they doing, how are hours like during the day? What does the job market look like? Where do you want to live moving forward in the future? Those types of things, although nobody can predict what the job market looks like, there are certain things with certain subspecialties that are just always going to be an issue. There are always going to be family physician jobs all over the place, surgeon jobs are limited by OR capacity and hospital resources and that is going to be a fact for the foreseeable future. And so, those types of things, although hard to be certain about, should play an important role in people thinking about their subspecialties. Because if you really love a speciality, but you can’t find a future in the thing that you trained so long for in maybe a place that you and your loved ones want to live in it is going to be a challenge. So I definitely have seen friends and colleagues go through things like that, and it is important to consider in choosing a speciality. Like I said, podcasts like this and being able to talk to lots of different people in the subspecialty you are interested in, both in academia and in community is probably the best way to go about doing that. 

Lastly in otolaryngology, for any medical students interested in otolaryngology, come on down. Come talk to the otolaryngologists, talk to as many people as you can. We are really a small community and everybody is exceptionally friendly and receptive to learners and people who are interested to know more and it is difficult to maybe initiate or say hi and kind of take the next step. You definitely can’t lose by trying and putting yourself out there and one of my favorite memories was going to CSO, the Canadian Society of Otolaryngology, annual meeting as a medical student. I wasn't presenting anything, I didn’t know anybody. I went with another medical student, who was also very keen on otolaryngology, and we went there and half the time we were standing around watching presentations thinking I want to talk to this person, I want to talk to that person, and you kind of make yourself do it. It was a great experience, and some of the mentors remember me approaching them. It is a great way to network, a great way to meet people and understand if the speciality is right for you. So definitely say hi, send an email it never hurts and you never know what might happen. 

Huaqi Li: Thank you so much Dr. Xu, it was really great to hear the different stories when you were a medical student, everything like that. Thank you so much for taking time out of your very busy schedule to chat with us today and thank you to all our listeners who tuned in. We hope to see you back here for our next episode.