In this episode of MedCast, Dr. Stephen Rockower talks with Dr. Douglas Reh, an otolaryngologist in Baltimore County. They discuss all things noses and ears, including legislation that found its way working through the Maryland General Assembly and how advocacy directly from otolaryngologists played a role in shaping that legislative effort.
Steven Rockower
Welcome to Med Cast Podcast from Med Chi, the Maryland State Medical Society. Each episode we'll be doing a deep dive into medicine and taking an insider's view on issues facing Maryland's physicians, patients, and healthcare more broadly. I'm your host, Dr. Steven Rockower. Today my guest is Dr. Douglas Reh, an otolaryngologist in Baltimore County, and he'll be talking about otolaryngology and all things noses and ears. Welcome, Dr. Reh.
Douglas Reh
Thanks for having me on, Steve. I'm excited to be here.
Steven Rockower
Well, I'm glad to have you. This is an important topic. Why don't we start a little bit by telling me about where you went to school and where you did your training and how you got into otolaryngology?
Douglas Reh
Sure. Yeah. I actually grew up in Western New York and went to undergraduate in Boston at Boston College and then started medical school and attended medical school at the University of Rochester. And after completing medical school, I went to residency in Portland, Oregon at Oregon Health Science University, OHSU, where I did a five year residency program in otolaryngology. Something to know about otolaryngology for those who aren't as familiar with it, we are the traditional name for us as ear, nose and throat doctors and surgeons we're both doctors and surgeons. And so we treat disorders of the nose, the nose, the sinuses, the throat, the ears. We take out tonsils, we put tubes in for your kids when they have ear infections and we can subspecialize so we can find different areas to do extra training just like you as an orthopedic surgeon can do extra training.
And so I did a year of fellowship in endoscopic sinus and skull base surgery, so that's minimally invasive sinus and skull base in nasal surgery for tumors and for chronic sinusitis. And I did that in Boston at Harvard at Mass Eye and Ear. And then completing my fellowship, I was recruited to Johns Hopkins and I became one of their assistant professors and then was later promoted and was sort of their clinical rhinologist, sinus surgeon, and did a lot of big surgeries with the neurosurgeons, taking out big skull base tumors through the nose. And I was actually the residency director there for five years. And then in 2017, I sort of decided that I had done academic medicine for long enough and I kind of wanted a little bit more control over my life. So I joined a colleague who was also at Hopkins prior to me, Mark Dubin, and joined a private practice in Baltimore County.
It's one of the older practices in Baltimore County, and we've since merged with other practices in the state and then nationally to join a large group practice. So we're part of what's called the Centers for Advanced ENT Care in Maryland. We're a multispecialty ENT group, so we have one of our partners did a fellowship in facial plastics. Another one of our partners is specialized in ears and otologic surgery. And then we have general practice ENTs in our group that just do everything, ear tubes, adenoids, tonsils, neck tumors, facial tumors and all that kind of thing. So I've been in practice here almost 20 years and have been in practice in Baltimore County for most of that time. And so that's sort of my story in a nutshell.
Steven Rockower
That's very fascinating. Mine is similar in orthopedics down here in Washington. So with ENT people, you also have worked with audiologists in your practice, what distinguishes ENT doctors from audiologists?
Douglas Reh
Yeah, so audiologists are a really important group of clinical providers because they treat all types of diseases involving the auditory and the vestibular systems. So the hearing and balance systems, and most ENT groups like ours hire and work with audiologists. And I think we have six audiologists in our practice. And so on a given day, I'll see, even though I focus mostly on the nose and sinuses, I'd say a third of my patients, 25 to 30% on a given day have issues with their auditory systems. And so our audiologists will perform an audiogram and test their middle ear function and test their hearing. We also sell a lot of hearing aids through our practice. And so the audiologist will, they do all of that. They sit down with a patient, they go over their options for what the best hearing aid system is for their particular level of hearing loss or their particular issue. So they're a really important part of our delivery of care in our practice and in the state.
Steven Rockower
And there was a bill last year that changed their practice pattern. Could you talk a little bit about that and how things tried to get changed this year?
Douglas Reh
Yeah, so a little bit of sort of segue into that is that I as an ENT, obviously we each have our own societies and we have a Maryland Society of Otolaryngology, and I've been a member for many, many years and I'm now the president of the Maryland Society of Otolaryngology. So I came in just about four months ago into this and have been brought up to speed about the importance of advocacy and what that means for us as ENTs and what it means for us as physicians in Maryland. But essentially, and I've been hearing about this attempt by the audiologist for many, many years, but the audiologists in Maryland have for years been pushing in our state legislature to expand their scope of practice. And the legislation that they've eventually passed, and we can talk about that contains three main provisions, which is that this new expansion of their scope of practice allows the audiologist to conduct health screenings with really no limit on the parameters of those screenings.
So they can do a health screening of all different parts of a patient's, of their health history. It allows them the audiologist to order cultures and blood work. And it also allows audiologists to order imaging studies like for the inner ear MRI scans or CT scans. So this is essentially an attempt by them to expand their scope of practice. So this has gone through the legislature for many, many years, but in October of last year, the legislation actually was passed, and it's the first real bill of this type in the country. Maryland is the only state that's passed this bill that expands their scope of practice. There's been other bills that have been put forth in the legislature in Arkansas and Oregon to do similar things. Interestingly, a couple of weeks ago, the bill was voted down in Arkansas, so that bill is not going to go up in front of the legislature. It was not presented as a bill. So again, this is the only bill of its kind because of the nature of the bill and the expansion of practice of the audiologists. It's garnered a lot of attention by our national academy, the Academy of the American Academy of Otolaryngology. So in my role here talking to you, I'm serving sort of as a person involved in both the Academy of Otolaryngology, which is the national organization and the Maryland Society of Otolaryngology, which is our state society.
Steven Rockower
Well, we seem to hope that our podcasts have a national audience, so I'm happy to have you talk like this.
Douglas Reh
Yeah, and I would certainly forward this podcast on to our academy, and hopefully we can get your permission to put it out there too for our national otolaryngologist to hear us.
Steven Rockower
Right. We go internationally. Exactly. So the law that got passed and seemed to overly expand the scope of practice for the audiologists, how were we trying to change that this year?
Douglas Reh
So we've worked with MedChi and on our behalf, MedChi applied for an advocacy grant through the A MA and we received that. So we've been able to hire lobbyists and we've been working with a lobbyists to sort of put new language into the bill. I should take a step back here and Steve and point out this is sort of an important piece of information. Well, the legislature passed this new expansion of their scope of practice. Our governor, he had some serious concerns about the bill, so he didn't sign the bill. Now, the way it works is that the bill still has been passed by the state legislature, but the governor didn't sign it because of his concerns and actually has asked us to sort of work together to modify the language. So we, through MedChi, we're able to hire some lobbyists to work with the lobbyists, the audiologist lobbyists, to try to change the language so that it's sort of, I think more meaningful and fixes some of the critical issues we see with this expansion of their scope of practice
Steven Rockower
With, correct me if I'm wrong, but even though the governor didn't sign it, it still went at the law,
Douglas Reh
Correct.
Steven Rockower
Right.
Douglas Reh
So it does in Maryland expand their scope of practice. And so we've been trying to work with them and negotiate with them to put in parameters around the health screening provisions. And frankly, we really want to just eliminate the portion of the bill that allows them to order blood work and cultures. Unfortunately, we haven't made a lot of progress in that area and been able to come to a compromise with 'em. So our stance right now in terms of the Maryland Society of Otolaryngology and the Academy is that we don't really accept the bill is a law now, but we don't really support it and we don't feel that it's in the best interest of our patients and our state constituents going forward. And so we're not supportive of the bill in its current state.
Steven Rockower
Right. And in this year's session of the legislature, there was a bill to try to correct some of these problems in last year's bill, is that correct?
Douglas Reh
Right. We were trying to pass a new bill that would modify the language to the existing bill.
Steven Rockower
Unfortunately,
Douglas Reh
We weren't able to come up with a compromise that we thought was a reasonable compromise. So at this point, our academy is not supportive of the bill that was passed in Maryland
Steven Rockower
Of the bill that was passed last year,
Douglas Reh
Correct.
Steven Rockower
Correct. And this year's Bill has not had a lot of support, is my understanding
Douglas Reh
Correct. To be honest, we haven't been able to achieve a consensus between us and the audiologists as to what the changes that need to be made in the new bill to change that language. The fact of the matter is, Steve, it's a bill, and so we're sort of swimming upstream with this right now. There's nothing that forces them to change the language of the bill, but we're trying to put it out there that we don't think the bill promotes patient safety and does the things that we think are right for the patients in Maryland. And for that reason, we're sort of fighting to make necessary changes to it.
Steven Rockower
So it didn't go through this year, so we'll have to try to come back next year with a similar bill and have the rest of the audiology or the ENT and otolaryngology physicians work in advocacy to help convince legislators of what needs to be fixed. You're head of the Maryland Otolaryngology Association. What can the association do to inform your members what needs to be done?
Douglas Reh
Well, so certainly we're trying to rally our otolaryngologist in Maryland to sort of talk to their state legislatures. And we're planning on meeting with them probably more towards the summer or the end of the summer, just to see if we can get some traction to get someone to take ownership and be a champion of a bill that would change the language. And just if you give me a minute, Steve, I can talk a little bit about what we're concerned about with this bill, just because really what we think it does is it expands the audiologist scope of practice in such a way that it doesn't necessarily lead towards better patient care, because what it does is it essentially expands their role in healthcare and their scope of practice without demanding commensurate training to have them trained to meet these new scope of practice. So we work with, as I said, audiologists are very important in taking care of our patients, and they deliver excellent care in their previous scope of practice, but they're not trained to identify pathologic diseases in the ear or identify tumors or masses or other things, infections.
And so one of the things that they sort of brought up and we're trying to push is that this basically allowed this new bill would allow patients with improved access to care and thereby would improve patients' overall care. But we've sort of argued with, we've sort of disagreed with that comment. And first because one of the strong statements by the audiologists and their lobbyists is that in rural areas in Maryland, it's harder for a patient to get in to see an ENT to get this care, and that if an audiologist sees the patient, they can just order these lab tests appropriately and that it improves patient access to care. But the reality is that the density of audiologists practicing in the urban areas isn't significantly different than the density of ENTs practicing in urban practices. And we all have good relationships with our audiologists. So it's not hard if an audiologist identifies something that needs to be checked out by an ear, nose and throat doctor, that's easy for them to refer them, whether they're in an urban or a rural environment.
So certainly, sorry, I meant to say rural, but in the rural areas, there's just as many density of ENTs as there are audiologists, and we can provide them care in either setting. But one of the things we're trying to educate people on is that they talk about ear cultures or sending cultures. Well, Steve, I'll tell you, I probably do like four or five ear cultures a year as compared to thousands of sinus cultures or throat cultures. We don't generally have to culture the ear we treat, and then in rare cases we culture. But the kinds of things that we are concerned with, and I can give you a little bit of an anecdote here, is on a daily basis, my audiologist will say, Hey, Doug, I see something weird in this ear canal, or I see something weird in the ear. Can you take a look?
And sometimes it's normal anatomy or sometimes it's an infection that needs to be treated. And I'll say, well, gee, thanks for picking that up. This patient has an infection and I'll treat, but I don't order a culture, I just give them drops or whatever antibiotics they need. And so this concept that it's going to delay a patient access because they'll just treat appropriately, they'll just get the culture. It doesn't really improve patient access because let's say they see something that they don't understand in the ear and then they get a culture, but they didn't really need to get a culture. And that will delay the patient getting into see an ENT, and it may be just a normal variant of anatomy and they've got a culture when they didn't need to. The other thing is when we order these tests, you have to associate a diagnosis code with these tests.
And so as you know Steve, if you don't have the proper diagnosis code, it delays the test. So the insurance company will come back and say, well, you don't have the right diagnosis code. Well, if they're not sure what they're looking at or they're not sure what the diagnosis is, but they're ordering tests that actually can be a delay of care for the patient rather than just referring them to an ENT who can diagnose the problem and then order the appropriate tests. So we actually would argue that this bill allows for inappropriate tests to be ordered or can actually delay patient care or delay their access to care and actually could end up with treatments that are prescribed that aren't the appropriate treatments.
Steven Rockower
And did they have the same kind of training that physicians have?
Douglas Reh:
No, no. We go through four years of medical school and in five years of residency, and we are trained to identify pathology of the ear both through audiograms that we see or through things that we can visualize through an endoscopic microscope. Audiologists are trained to test the hearing and to assess the vestibular system, but they're not really, and they may in their internship, learn how to take out wax in limited form, and that's fine so that they can see the hepatic membrane, but they're not really trained to identify pathological disease in the inner ear, the middle ear, the ear canal, identify infection or treat infection or treat any type of disease that they could see in the ear that's not part of their training.
Steven Rockower:
Okay. And do they take, we're subject to taking continuing medical education. Do they have similar requirements that they might get anything training like that?
Douglas Reh:
Currently? No. And that's one of our issues with the bill is that when they pass this bill to increase their scope of practice, they didn't stipulate that the audiologists need to be trained on the types of things that they would see or do to order these tests correctly.
Steven Rockower:
So from this point, the otolaryngologists here in Maryland need to work on advocacy to the legislature legislators to craft a bill for next year that will help correct the problems. What kind of steps would you suggest for your fellows to take to contact the legislators and what sort of points do they need to make?
Douglas Reh:
Well, I think first of all, I am new into the advocacy world, Steve, and I think most physicians, I'm not even going to say ENTs, but most physicians, we don't really put a lot of effort into advocacy, and it's a real problem. Doctors are sort of siloed into our worlds of patient care and our practices and our families, and we don't really think about advocacy. But then certain we really do need to advocate both for ourselves and for our patients. And we are a tremendous resource for our state legislators, and we can in a positive way, educate them because they didn't go through medical school or residency. They don't understand these types of things that we see on a day in, on a daily basis. So I've sort of learned over this year in getting involved in our Maryland Society of Otolaryngology and also part of the American Academy of Otolaryngology PAC Board, which is our physician advisor council.
And I've learned that advocacy is so important for us because if we don't educate our legislators about these types of bills and when bills come in to the state and then they're discussed, we need to be aware of them and we need to be aware of how they impact us and about how they impact our patients. Because the thing that I've really learned about this bill in Maryland is that by the time it's going to be voted on, it's probably got significant support in the state legislature. And so the time to get involved is when these bills are first introduced into committees and discussed. And that's when we need to serve as expert experts to sort of educate people about what the impact of these bills are. And so I would urge everyone to be sort of aware through your state society, through MedChi, and we all do a pretty good job of educating or trying to put out the information for our physicians about what's coming, what we should be concerned with.
And then we usually will tell the physicians like, this is something that you need to advocate. So then you contact your state representative and you can send them an email or a message. They're all easy to contact and say, I have concerns and these are what my concerns are. So if this audiology bill is a concern, I think we've sort of, you and I have sort of talked about that today about the important aspects of this bill that we have concerns about. You can sort of in bullet points pass that along to your state representative to let them know.
Steven Rockower:
Anybody listening to this podcast who has heard me in the past knows how much I believe in advocacy. I've been doing this for probably 30 years on the MedChi level. The time to start advocating is really over the summer when the legislators are having fundraisers, meet and greets, and you pay $25 or $50 and you get 30 or 40 people, and you just sit around and chat, and you can talk to the legislators then either about your bill or anything else in your local area, get a stop sign at this corner or change the street signs or something like that. But then they get to know you. And so when it does come time during the legislative session from January to April, they know that you're a straight shooter and then they'll spend some time to listen to you. And they don't always listen and well, they always listen.
They don't always agree with us as we found out, but you get to know who your people are. And as far as raising money, people have also known that I'm involved with the Maryland Medical PAC to help raise money for our lobbyists for MedChi, to be able to talk to our legislators and work through the things that MedChi is interested in, especially in this audiology bill, but everything else. So we have to support each other. Sometimes the audiologists need, the ENTs need the help. Sometimes the OB GYNs need the help. Sometimes the orthopedists need the help. And so we all have to work together. So I'll get off my soapbox now.
Douglas Reh:
No, but Steve, I mean, I think you raised a really great point. And again, I've been in practice for 20 years and I'm just sort of learning about this now. And I know our National Academy, Academy of Otolaryngology, our PAC spends a lot of time trying to educate our otolaryngologists, our national members about the importance of giving money towards the PAC and also being aware of what's going on in their individual states and at a national level so that they can advocate for themselves. And I think that this bill that was passed in Maryland is certainly a great example of what can happen if we're not paying attention. And our PAC got involved in Arkansas and was able to prevent that bill from going to be voted on. So it just shows that a little bit of knowledge and a little bit of paying attention and a little bit of advocacy can go a long way towards helping our patients.
Steven Rockower:
Well, I've always said that what happens in Annapolis makes much more difference in our lives than what happens in DC even though what happens in DC does make a big difference. But it is important for everybody, every physician working in Maryland to pay attention to the weekly emails to say what's going on. And I'll also make a pitch for getting involved in the legislative sessions that discusses the bills, and you can add all of your expertise to each of the bills coming through.
Douglas Reh:
Yeah, I think I saw a MedChi email come across in the last 48 hours, about a 3% increase in it, a tax on IT, which obviously because we're all dependent on IT is going to increase our costs and those costs may get passed on to our patients.
Steven Rockower:
Yes, and unfortunately, unless you're in a cash practice, you really have to absorb that extra cost because the insurance companies are not going to pay you anymore. Correct. Okay. Well, let's switch gears. What would you be doing if you were not a physician?
Douglas Reh:
That's a great question. I really like being outside, Steve. So I think I like hiking around or doing things outside, not close to retirement, but it's not, I'm closer to retiring than I am closer to the end of my career than I am to the beginning. And so my wife, who likes me in small doses, has told me I need a hobby because my kids are all almost out of the house. And so I started learning golf this year, and I like being outside and learning golf, although I'm terrible at it, so I don't know. And I want paragliding in Switzerland, so maybe I become a professional paraglider or maybe a golf caddy. Those two things strike me as a nice job.
Steven Rockower:
Well, as an orthopedist, I think that's absolutely good for you to do because that'll give us some business.
Douglas Reh:
Exactly. When I crash into the side of a mountain, I'll call
Steven Rockower:
Exactly, exactly. What advice would you give to your younger self?
Douglas Reh:
Yeah, I'm a person that's made big changes in my life. I didn't say this initially, but I was actually a finance major undergrad, and I started working, doing financial services consulting, and then three years into it said, this is not going to work for me. And I made a big life change, and then I became an ENT, and then I was in academics, and then I made another big life change into private practice. And all of these have really worked out for me. So I guess the first thing, and they were very stressful, all of these changes I made in my life were at the time, super stressful. When I left Hopkins and I went into private practice, I don't think I slept well for a year, but it's always in the end benefited me and my family. So I guess the first thing I would tell my younger self is to not be afraid to make a leap or a big change.
The other thing I've always said when I was, I still work with the residents at our community hospital, the residents from Hopkins, and I love teaching. It's the thing I miss about Hopkins, and I always say, you always have to be changing what you do, and you always have to be asking, be curious and ask people, well, how do they do it? Or how do they do it? And always try to change and evolve as a surgeon, as a physician, as a person. If you're not changing, you're sort of deteriorating and dying. And I think growth is such an important part of life. So I would say just keep learning and doing new things so that you're always growing. That be what I tell myself.
Steven Rockower:
Okay. That's wonderful. Talk to me a little bit about your path to leadership. You said you're head of your organization. How did you get into advocacy and working within the medical community to that, and what would you advise other people to do?
Douglas Reh:
Well, so the funny thing about this, Steve, is that me being president of the Maryland Society of Otolaryngology, that's a job that nobody ever wants, right? I'm sure you understand that. Done that it would be like we would have our state meetings every year, and I would go and it would be like in someone, everyone stand up and everyone that wants to volunteer to be the president of the MSO take one step forward, and then everyone would take a step backwards except for one person, and they would look around and be it. So I sort of got thrust into this a lot because of the audiology bill, and we were having issues with our finances in the MSO, and it just needed to get fixed. And so someone who knows me well, I'm a pretty good implementer, I'm a pretty good, roll up your sleeves and get something fixed.
So that's how I sort of ended up as president of the MSO. But all things in life, you get stuck in something and you're trying to fix it, and then you say to yourself, this is a growth opportunity. I'm really learning a lot here. So I mean, I didn't know what MedChi was. I didn't know, understand how things work with our state legislature. I'm learning all these things. And then I got involved in the academy in our PAC, and there's just wonderful people that are part of this, our advisory council, and I've learned from them and sort of the importance of it. And then you and I were just talking, I have a partner, Annette Fam, who you've worked with, she's in Montgomery County with you, and she's done this her whole career. And I was talking to her last night and I just said, this is all new to me. And she loves it. She just, the people that you meet and learned and grow from, because we're all a community and we all have to look out for each other and look out for our patients. And this sort of allows you that opportunity. So I think for me, I think of it less as leadership and more as just a collaboration with people. And I like to meet and work with people. I am getting to meet you and talk to you. So it's been a good experience.
Steven Rockower:
Well, as I said, I'm on sort of the downside of my career. I've already retired, but being involved is sort of been what I've been part of my whole life, and 90% of life is showing up. And so one of our concerns is you said you didn't have much of a knowledge about MedChi or advocacy while you were in academic practice. If you could somehow get back to your previous colleagues in academia and tell them of the advantages of dealing with MedChi, because we're working for everybody, all physicians in Maryland, not only the people who are members, but we're working for everybody, and we're hoping that you can help join in and work with us. So I think this has been a great conversation. Thank you to Dr. Douglas Reh.
Douglas Reh:
Yeah, thanks for having me, Steve,
Steven Rockower:
Thank you to Dr. Douglas Reh who has been our guest on MedCast, the podcast from MedChi, the Maryland State Medical Society. Tune in next time as we continue our conversations with the leaders of medicine in Maryland to discuss the issues facing physicians and our patients. For all of us here at MedChi, I'm Dr. Steven Rockower. Thank you, and goodbye.