michael johns, md
Published on July 13, 2016
Pleased to post an interview with Dr. Michael Johns, laryngeal surgeon and the Director of University of Southern California Voice Center. He was recently named one of the top 10 laryngologists in the country by the Billboard magazine. Please credit The Voice Forum when you share our content. http://www.keckmedicine.org/the-keck-effect-more-volume/ #fellowshipofthelarynx
TVF: Is it true that you tried your hands on a career other than laryngology?
MJ: Yes I have. I was initially interested in business, finance, and banking. I was an economics major at the University of Virginia and spent a summer at the Lake Continental Bank in Chicago doing credit work which was hideously boring. One missed opportunity was opening up and owning a Starbucks franchise in Baltimore and Washington which was sadly shot down by the Starbucks company itself. Demoralization by the business world led me back to what I was actually good at, which is the sciences. That led me to medical school at Johns Hopkins. I am also a child of a successful physician who was a Head and Neck surgeo,who was the chair of the department of Otolaryngology at Johns Hopkins when I was in middle and high school. When I went to college he became the Dean of the school of the medicine there. He was the dean even when I went to medical school at Johns Hopkins. That’s how I got in. (jokingly laughs).
TVF: You recently moved your practice from Emory Voice Center in Atlanta to University of Southern California (USC). Tell us about your career.
MJ: So Norm Hogikyan is my mentor who drew me to laryngology during my otolaryngology residency at University of Michigan. After that, Doug Mattox who was the chair at Emory wanted me to join the faculty and start a laryngology program. He asked me to do a laryngology fellowship. Bob Ossoff at Vanderbilt University offered me a fellowship, which I enthusiastically accepted. I worked with Gaelyn Garrett, Mark Courey, and Bob Ossoff at Vanderbilt for a year. It was a great training there. What I got out of that fellowship experience is the modern model of care for patients with voice and swallow disorders. The true interdisciplinary approach that is so rare around the country. So I brought that to Emory. Tom Cleveland knew what I wanted to do and introduced me to Edie Hapner. I knew I needed a skilled partner someone who was like minded. She had done her Ph.D. at Vanderbilt after many years in clinical practice and was ready to get back into academia. We started the Emory Voice Center. We grew the program to 4 laryngologists and 6 Speech-Language Pathologists over the course of 12 years. I was totally happy at Emory and I got engaged. My fiancé was in Los Angeles permanently so I was traveling back and forth frequently. I happened to talk to John Niparko at USC asked me about how they can emulate what Emory has done in USC. I gave him some ideas and he asked me to craft a written proposal which I did. Then he asked me if I would do it at USC. The USC Voice Center was born.
TVF: In your opinion, what is the most concerning issues in Voice Disorders?
MJ: It is over diagnosis that serves the clinician. Over diagnosis of paresis and reflux. The reflux pendulum has swung back from wild diagnosis to rather rational approach to the role of acid reflux. In a setting of lack of knowledge, some physician forwarded reflux being the champion of most benign laryngeal disease and it took off. As we gained more knowledge the pendulum swung the other direction. I feel like the same is occurring with vocal fold paresis which is being frequently diagnosed based on very subtle asymmetries of vocal fold movement and vibration. And it’s my pet peeve. People have asymmetries in their bodies. When you ask me to lift a weight with my right hand I can perform that task for a certain period of time and certain amount of weight. If you ask me to do the same task with my left hand, it will be slightly different. We are not symmetrical. To ascribe a diagnosis of paresis for subtle asymmetry of larynx is illogical. The idea that most peoples are suffering from some sort of cranial neuropathy is unlikely.
TVF: What do you think has been the most important improvement in the field of voice in the recent years?
MJ: I think I would say first and foremost, the most voice disorders that we see are largely can benefit from behavioral intervention. So evolution of voice therapy in two domains, one in terms of awareness and education of people about how important voice therapy is and how to deliver it, but more importantly than that, different techniques of voice therapy that are appropriate for certain disorders. One type therapy isn’t appropriate for every disorder. (I’m not an SLP but I offer my opinion garnered through our discussions, observations of therapy outcomes, and the research) Do old people get vocal nodules? No they don’t. It’s a hypofunctional voice disorder. They need a different type of voice therapy that is energized. Our understanding of what is appropriate therapy for a given diagnosis is our biggest breakthrough in voice.
So I will give the advancement in behavioral modification through voice therapy more importance than our ability to use modern technologies to treat laryngeal disease. The reality is, in my clinic, 95% of patients that I see are non-surgical patients. They are patients that will be treated with medical or behavioral intervention. And maybe 1/20 are surgical patients.
TVF: What do you think about vocal fry?
MJ: To be frank I think it’s a cosmetic issue. It’s gotten a lot of press lately. Do I think it’s traumatic? I don’t. I think that mechanism of pulse mode phonation doesn’t deliver one’s message as effectively as resonant voice but I don’t think its traumatic. That mode of phonation is not traumatic to the vocal fold mucosa. You may feel discomfort or vocal fatigue down the line which is a functional pathology, but it’s not an irreversible problem like vocal fold scar or other things we deal with. It just doesn’t sound good and doesn’t put your best face forward men or women alike. I used to speak in vocal fry like most medical students do until SLPs at Michigan motivated me to use my resonant voice. I think I am much more interesting and engaging (just ask my mother!), and I can deliver my message more powerfully in oral tone.
TVF: What is your most memorable voice case?
MJ: A female patient, who was uninsured, got admitted, intubated for Urogynological problem, ended up getting hysterectomy, prolonged intubation for post op complications, and tracheotomy placed. Ended up with complete suprastomal tracheostenosis with normal larynx. It was neglected based on her social economic status and was aphonic for two years. We opened the stenosis, placed a T tube, and in one operation restored her voice. She went from someone who couldn’t speak for 2 years to someone who can immediately speak post op. It was compelling to me. Someone without resources and struggling without voice for two years, that was probably my most moving case.
TVF: What are your research interest and why, how can we use it clinically?
MJ: I like the aging voice. It’s an important problem. When I went to Atlanta and started the voice center, there was very little written about prevalence of presbyphonia, impact on individual’s quality of life, at the same time the baby boomer generation population was getting older. 30% of population will over age 65 soon, living longer and and wanting to live a more productive lives both socially and occupationally, it became an interest of mine. And I did a few studies.
The things we have done was understanding quality of life (QOL) issues and developing novel voice therapies for aging voice speared by Edie Hapner and Aaron Ziegler. Previously it was thought that traditional therapy approaches were most appropriate. In reality these people need to power up their voices energetically. With novel therapies forthcoming, now we have ability to augment the vocal folds as an adjunct to voice therapy in the awake setting because the barrier to treatment to our older individuals are anesthesia and transportation. What we really need to get to develop vocal fold tissue regeneration both in the mucosa and the body of the vocal fold to complement behavioral strategies.
“Our voice is a reflection of our souls and our vitality” – Michael Johns, MD
If vitality is impaired, you will hear it in your voice.
TVF: What is lacking in training of laryngologists and Speech-Language Pathologists (SLPs)?
MJ: Given that Laryngology is a specialty area in Otolaryngology, I think it is hard to compare Laryngology training to SLP training. Just as Otolaryngology is a generalist degree, SLP is a generalist degree and it is not until internships and fellowships that SLPs can benefit from focused training in the current SLP training model. The medical model of fellowship is way more structured than Speech pathology clinical fellowships in general. SLP fellowships in Voice and Swallowing have brought the curriculum driven model to Speech Pathology and I think that our future SLPs will feel more comfortable in their delivery of therapy, their research, and their interprofessional practice given the curriculum based specialty models emerging. Clinical fellowships in speech pathology around US are often “a rent to own program” where you are hired at low level salaries and start working. You learn on the job and you may or may not get any instructions from peers around you, and it is not curriculum driven.
TVF: Do you think voice SLPs need some sort of a certification program?
MJ: The short answer is no. But you need to have some criteria structured around training programs for SLPs interested in voice, which is a different thing than certification.
For example, there is no certification in laryngology. Laryngology is well defined at this point with identified curricular elements that need to be satisfied to have a program that is educationally sound. That doesn’t exist for SLPs. And that was our goal with our clinical fellowship in SLP at Emory which we are going to continuing at USC, is to have a curricular based program. We don’t hire our fellows and they spend one year with us with certain set of learning objects and educational content and clinical experiences built around that to educate individuals. I think that’s way more important than certification.
To certify someone is a process that is prohibitively expensive in a small field and there is limited control of programs offering certification.
TVF: As a surgeon, what keeps you on your toes?
MJ: Airway because what are the ABCs of CPR? Airway, breathing, circulation. It’s high pressure, mission critical, life or death. Stenosis, angioedema, tumors, difficult intubations, it’s all about securing the airway.
TVF: What advice do you have for aspiring laryngologists?
MJ: Love your field. Find a simple fundamental question that intrigues you and dig deep. It can be clinical. It can be basic. Just explore what you find interesting. Leverage expertise at your institution as it aligns with your interests. It's a team effort, always.
TVF: The “voice” community is a very tight knit group of medical professionals, pedagogues, scientists, and vocal performers of many genres. What can we learn from each other?
MJ: All of our practices focus on the larynx to a certain degree. Staying connected with our allied colleagues allows us to learn from each other and understand each others’ perspective on the voice, hence #fellowshipofthelarynx
TVF: What advise do you want to give to the lay public about voice?
MJ: If you have a chronic voice disorder, seek care from a fellowship trained laryngologist. They will direct to to the right care.
TVF: Who are your favorite singers?
MJ: My two favorite female vocalists hands down are Stevie Nicks and Karen Carpenter. Stevie Nicks because she had this rich low sultry voice that drives me. And Karen Carpenter with beautiful cleanness that you rarely hear. My two favorite male vocalists are Peter Gabriel and Jerry Garcia. Peter Gabriel has a phenomenal, diverse vocal musical career from Genesis to his own independent work and has incredible vocal talent. The second is Jerry Garcia from the Grateful Dead. Not only is his voice phenomenal, the prosody of his guitar playing is intoxicating. I like the poetic message in their lyrics. I tell people that mentorship drew me to laryngology but I think the background behind it is my love for music, not as a performer or a producer but as someone who appreciates it. And I do like singing.
TVF: What sparks joy for you?
MJ: Yoga. It’s mentally and physically nourishing. It’s a moving meditation that allows me to focus in the moment.