Back for more! Week two & three of the special series on Cochlear Implants. This week we hear all about Candidacy with Terry Zwolan, PhD, Melissa Hall, AuD, Craig Buchman, MD, Ted McRackan, MD, Paul Shea, MD and Matt Bush, MD.

Check out today’s newest episodes!

Episode 7: Terry Zwolan, PhD | Cochlear Implants Series, Finding the Easy Button | If you were looking at a timeline of impactful events in cochlear implant history, you’d find Dr. Terry Zwolan’s name listed on a lot of them. This episode touches on one of her latest, the 60/60 – which is a simple way to know if the patient in front of you should be considered for CI. She talks candidacy, new codes and everything in between.

Episode 8: Melissa Hall, AuD, SLP | This episode focuses on the kiddos, and the village of providers, specialists, family and friends that are needed to not only help them find success, but that work hard to ensure that these children are thriving.  From identifying this population, to understanding the red flags, to asking more specific questions, Dr. Hall covers a lot of ground.  Listen up and get caught up with what is happening in pediatrics and cochlear implants.

Episode 9: Craig Buchman, MD | Cochlear Implant Series, Candidacy, Outcomes & Oddball Cases | This episode digs into cochlear implant candidacy and loops listeners into some of the most up-to-date changes that were announced by CMS. Dr. Buchman shares his perspective on where the specialty is going, outcomes, why they are focusing on hearing preservation, and even reveals some less thought about indications that maybe should trigger a referral for a CI assessment.

Episode 10: Ted McRackan, MD | Cochlear Implant Series, Real-Life Outcomes & Quality of Life | What picture do you have framed on your desk to help remind you not to make assumptions about patients?  Listen as Dr. Ted McRackan talks real-life outcomes of patients with CI, and dives headfirst into the Cochlear Implant Quality of Life Profile (CIQOL) framework. He relays challenges in connecting test results with a patient’s perceived real-world function, and shares insight into how providers can use this type of data during discussions of expectations with potential CI users and throughout a CI patient’s care. 

Episode 11: Paul Shea, MD | Cochlear Implants Series, When a patient is 90 years young. Should we consider an implant? A surgeon’s perspective | This episode provides insight into the candidacy decision and conversations that happened before KK’s mom had her cochlear implant surgery at age 90 years young.  Dr. Shea also talks neurotology, cochlear implants and private practice; and the collaboration needed to facilitate the best care for prospective cochlear implant candidates.  

Episode 12: Matt Bush, MD | Cochlear Implant Series, Available but not accessible, talking health disparity, access, and fixing problems together.  In this episode, Dr. Matt Bush talks about approaching the hard issues of delivering care in low resource communities and developing trust. Find out what’s being done, and the collaborative approach needed to continue to open the door to access.

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Joining the MedAudPro Provider Community is a great way to support our show, get free access to behind the password content and interact with other providers looking to practice at the top of their game. Subscribe today at bit.ly/JoinMedAudPro

This episode is sponsored by Envoy Medical.

Ever wish there was a fast way to get up to speed on a complicated topic? Well, you’re in luck. This series might just be for you. As providers, it’s hard to stay on top of all the specialties in a multi-specialty world. So join us for the month of October and get back in the loop about everything that’s happening in cochlear implants from the fundamentals, candidacy, patient characteristics and the latest in tech – and you’re going to hear it from the best of the best.

This series drops in groups of episodes each week, served up in a sprint, through the month of October ending the week of November 7th. The goal is to help busy providers stay at the top of their game, by delivering the what’s happening, how we got here and where we’re going, in short episodes that are casual and easy to listen to. You can’t help but be just a little smarter by spending 20 minutes with one of these special guests. Who should be listening? Any provider who sits in front of a patient that may have hearing loss. Some episodes are narrow and detailed, focused on the otolaryngology & audiology of it all, but most are bigger picture and meant to bring in all the providers that are part of the patient’s journey to better hearing. If you practice along that continuum, than enjoy the catch-up by these impressive experts – if you know them, well, you know that you should listen up and if you don’t know these folks – then you’re in for real treat.

We open the series with the Fundamentals, basically a little overview and a little history; kicked off by Brent Lucas, CEO of Envoy Medical, followed up by my co-host, Camille Dunn, PhD. Then we meet Donna Sorkin, Jolie Fainberg, AuD, Aniket Saoji PhD and KK Gross. Next up, Candidacy with Terry Zwolan, PhD, Melissa Hall, AuD, Craig Buchman, MD, Ted McRackan, MD, Paul Shea, MD and Matt Bush, MD. Then we dive into Patient Characteristics with special guests Bruce Gantz, MD, William Shapiro, AuD, Jill Firzt, PhD, Rene Gifford, PhD, Sarah Sidlowski, AuD, PhD, and then rounding out the series with Tech and What’s Next featuring Lisa Aubert, MS, Ray Gamble, Victoria Carr-Brendel, PhD and Brent Lucas, JD. And keep your ears open for a few surprises along the way!

Check out today’s newest episodes below and be watching for the next group of episodes, dropping next week!

Episode 1: Cochlear Implants: Special Series | Introduction with Brent Lucas | Join us for the month of October for this special series on all the things that are happening in Cochlear Implants. Hear from the experts as they break down what is happening with CI in 2022. And if you’re wondering why the CEO of Envoy Medical is opening the series? Well, let’s find out!

Episode 2: Meet my Co-host, Camille Dunn, PhD | We wouldn’t be doing a CI podcast without her!  Meet Camille Dunn, PhD, CI expert audiologist, industry leader and genuinely kind and funny person that I’m lucky to call a friend.  I’m so glad she raised her hand and offered to co-host this much needed series on everything that is happening with Cochlear Implants.  I used to think that CI was for a small group of patients and that there was only a small group of providers that delivered the care – not any more.  CI in 2022 is breaking all the rules for the better of everyone – get in the loop quick with the short series podcast covering the fundamentals, candidacy, characteristics and tech – all with the best of the best.  

Episode 3: From patient to advocate, Donna Sorkin shares her extraordinary journey | Meet Donna Sorkin, the Executive Director of ACI Alliance.  She’s had quite a journey.  She gives credit to her audiologist that went above and beyond, in a time when recommending CI may not had been the norm.  That experience inspired her to become a champion of others and was the beginning of a new career of advocacy. Check out the ACI Alliance Provider Resources Here  

Episode 4: Walking the walk with Jolie Fainberg, AuD | Did you ever want to meet someone that has worked with all of the cochlear implant models that have ever been released in the US?  Well, now you have. Dr. Jolie Fainberg has quite the perspective on how the field has changed over the years.  Don’t miss out on the insight.

Episode 5: The Inventor Among Us, with Aniket Saoji, PhD | Do you remember what it felt like when you got the call that your patent was accepted?  me neither.  But this guy… he could tell a story.  Meet Dr. Aniket Saoji. He is an audiologist that understands the clinical and industry perspective, as he’s worked for the manufactures, he holds more patents than I can count on all my fingers and toes, and he sits at the helm of the audiology department at Mayo Clinic, Rochester MN.  

Episode 6: When Your Parent is the Patient. A Caregiver Perspective with KK Gross. In this episode, KK shares her experience with cochlear implants from the caregiver perspective.  Her mom, who had a sudden hearing loss in one ear over 30 years ago, decided she wanted a cochlear implant, at the young age of 90.  This short episode is an overview of that story.  

Stay up to date with us on LinkedIn, Facebook, Twitter and Instagram @MedAudPro.

Joining the MedAudPro Provider Community is a great way to support our show, get free access to behind the password content and interact with other providers looking to practice at the top of their game.  Subscribe today

This CI special series is sponsored by Envoy Medical.

From Genomic Testing and Cell Therapies for Hearing Loss, Auditory Neuropathy Spectrum Disorder, Reviews & Education, to the Latest on OTC Hearing Aids – don’t miss the September/October 2022 Issue

ENT and Audiology News brings providers regular features and articles from contributors from around the globe; both the regular section editors and invited guest editors use their experience, expertise and interests to deliver the most relevant topics to today’s providers. Check out the regular features with news from around the world, journal, internet and book reviews, hands-on technical guides, product reviews, opinions on training and of course their famous course and events directory – where you’ll find information about this year’s Florida Combined Otolaryngology Meeting, happening at The Boca Raton, November 11-13!

Interested in checking it out? CLICK HERE to read the digital issue

Produced in Edinburgh, Scotland, ENT & Audiology News is a bi-monthly magazine, as well as online channel, that forges links between the ENT and audiology professions internationally. First-class articles are combined with conference news; book, journal and tech reviews, as well as all the latest news from the industry.

Now in its 30^th year and with readers in over 140 countries worldwide, this award-winning title has become essential reading for the profession and the platform of choice for companies wishing to reach the profession globally. Register for the print issue (free within the UK) or digital issue (free worldwide) and our monthly eNewsletter at: https://www.entandaudiologynews.com/register/

Join the brightest minds in ENT, head and neck surgery, facial plastic surgery, allergy, sleep, medical audiology and more for the 26th Annual Florida Combined Otolaryngology Meeting.

The primary event will take place in-person at the 200-acre, newly renovated, luxury resort property, The Boca Raton, located in Boca Raton, Florida, Nov. 11-13. The virtual meeting takes place the same dates, and based on feedback from last year’s attendees, will have on-demand, self-paced access through the end of November.

The FCOM2022 agenda features some of the brightest minds in ear, nose and throat medicine, head and neck surgery, facial plastic and reconstructive surgery, allergy, sleep, and medical audiology. Importantly, it will provide all participants with the opportunity to learn, connect and create lasting professional relationships with peers from throughout the U.S. and across the globe.

This modern-format meeting is designed to provide best-in-class engagement and promises to deliver an unparalleled experience that will enable all attendees, speakers, sponsors, and exhibitors to interact with one another by participating side-by-side during educational offerings, networking, and special events.

With more than 90 unique sessions, panel discussions, workshops, demonstrations, and sponsored events planned, there will be something for everyone. FCOM encourages all professionals involved in any aspect of otolaryngology to register for the event — including otolaryngologists, head and neck surgeons, facial plastic surgeons, allergists, sleep specialists, audiologists, nurse practitioners, physician assistants, audiology assistants, hearing care professionals, clinical and office staff, and students. CME and CEU credits are available.

Best meeting I’ve ever attended as a provider. What a difference it makes being at a conference with providers outside the field of audiology. Learning, networking and spending time in the expo hall with otolaryngologists, neuro-otologists, physician assistants, nurse practitioners and even the clinical and business folks really broadened my perspective on the topics presented.

John, AuD | FCOM Attendee 2021

Agenda Highlights | The opportunities for engagement are endless.

Below are a few examples of what is in store:

• Specialty Technology Sessions, a medical-industry session, pairs engineers and other thought-leaders — from industrial partners actively developing new tools for the otolaryngology community — with leading physicians who have pioneered their use clinically.
• The otology-medical audiology sessions will feature constructive interaction — geared toward collaboration and learning — among a cross section of providers focused on hearing challenges. This will include physicians, nurse practitioners, physician assistants, audiologists, audiology assistants and hearing care providers. Plus, there will be an industry-intensive session that will focus on future developments hearing and related disorders.
• For those in the field of obstructive sleep apnea, FCOM2022 will take an immersive look into this specialty — not only from the perspective of leading U.S. sleep apnea surgeons, but also from the viewpoint of those engineering pioneers and executives at the forefront of neuromodulation techniques and other technologic advancements in this field.
• A special session is in store for the facial plastic surgery community with the world-renowned facial plastic and reconstructive surgeon Dr. Paul Nassif, star of E!’s plastic surgery reality show “Botched” — which is sure to provide invaluable insight on how the specialty is viewed by the public.
• Special networking events are in place to increase access to our expert speakers and guests, all attendees are invited to attend the Friday Evening Margaritaville Speaker Event, EXPO Product Theatre Sessions, Interactive Exhibitor Activities, the Saturday Pre-game Tailgate Lunch Event and our 2^nd Annual Resident Bowl.

No matter your role within a company, CEO, administrator, clinical director to an entry-level position, soft skills are essential in helping you thrive in the workplace. They are so important that when something isn’t working or feels off, it is often rooted in a soft skillset vs. a technical skill mishap.  They are used and beneficial in any company, in any industry. If you find yourself with new work responsibility or the chance for one, soft skills are often one of the drivers for your newfound success, the reason you were hired, or why someone is trying to recruit you into a position.  #KnowYourStrengths #UnderstandYourWeaknesses #DoTheWork 

Here are some of the top soft skills that recruiters, hiring managers and business owners are looking for to drive success in a remote work environment:

• Accountability: Take responsibility for outcomes. This could be for an action you’ve done yourself, participated in as a team and most importantly, for your direct reports. The buck stops here – and you are the here.
• Assertiveness: Be confident in yourself and allow yourself the grace to not always be right. Don’t let fear of being wrong stop you from sharing and participating.  Acting courageous and enthusiastic with your communications and actions isn’t always easy, and it is often necessary. And don’t forget to balance your newfound assertiveness with respect, it will take you and your good work farther.  If you need to fake it till you become it, practice. 
• Collaboration & Teamwork: Do not be afraid to ask for help or to help others. Some tasks are better done together and partnering can get work done faster. Combine your efforts and resources toward a common goal and be respectful of others if they have a different viewpoint or method of getting a job done. In some instances, you may need to compromise. In others, do not be afraid to swallow your pride if the task gets completed in the desired outcome. It’s amazing what you can accomplish if you don’t care who gets credit.
• Conflict Management: Maintaining a healthy relationship with your coworkers is crucial to have a productive work environment. Conflict management is a skillset that helps you compromise and resolve disagreements in a respectful manner. Don’t let little things build up into big issues, and work to solve misunderstandings on a one-to-one basis first, in-person, video chat or over the phone – not in email or text.  
• Practical: Have calm, commonsense thinking. Think realistically when it comes to goals and outcomes and the time it will take to reach them. Setting unrealistic goals in unrealistic timeframes to often leads to failure and disappointment. This doesn’t mean you shouldn’t dream and push, if simply means that big visions need a level of practically to come true. 
• Creativity: Think, do, and express in ways that are outside of the box. This could be by creating new design ideas, processes or simply variations of current techniques to get tasks done. 
• Critical Thinking: Think in a disciplined manner that is clear, rational, open minded, and evidence based. Looking at problems from different points of view often opens new paths to solutions.  Take the side you disagree with most and argue for it – exercises like that will open your mind and allow you to determine options more openly.
• Enriching Others: Give positive reinforcement and support to those around you. Help create a healthy positive work environment. Be accepting of other’s differences. Mostly, find ways to contribute to the greater good of a project and others.
• Problem Solving: Hone the ability to identify obstacles. Discuss, analyze, and solve for challenges in both conventional and unconventional ways. 
• Productivity: Set and meet goals. Work hard but smart. Prioritize, plan, and manage tasks to knock them out of the way and to achieve your best results.
• Relationship Management: Build relationships with those around you. Be aware of their emotions and take them into consideration if they’re having a bad or unsuccessful day. Stop the often-natural tendency to think the worst and give everyone the benefit of the doubt.  You’ll appreciate it when they do the same for you.
• Self-Assessment: Self-reflect. Determine your strengths and limitations. See where you would add value to a situation or where you could improve and reach out for help. Often understanding your biggest weakness
• Service Orientation: Anticipate and meet people’s often unspoken needs. This can be done by helping them, introducing them to products, or services. Strive to achieve customer satisfaction and loyalty. Show them how you stand out from other places by being attentive and insightful. 
• Stress Tolerance: Be able to endure pressure and uncertainty without becoming negative toward self or others. Be able to handle fast-pace or changing environments or excessive workloads through proper management methods. Don’t be afraid to reach out for help when needed. 

As you read that list, did any skills resonate as talents you feel you may already possess?  How about those that stick out as opportunities for improvement? First, you should identify the soft skills you naturally align with or that you feel you already have mastered. These should appear under Strengths on your resume, during interviews, and as you look for ways to add value to your current team. 

Are you uncertain about what these might be? It’s sometimes hard to understand your strengths, particularly if it is something that comes more naturally.  A good way to identify the skills that should already be listed in your Strengths Column is to ask your current or former boss, talk with coworkers and close friends or take online assessments. Next, to strengthen the skills you feel are important but may lack mastery, read about them, inquire about training that may be available through your current job, or even take an online class. There are many online or in-person classes that vary in length and depth. It is also useful to interview someone who has the skill or skills you’re hoping to start working on. There is a lot to learn from those that are already practicing what you hope to develop.

As we think back to the first days of the pandemic lock down, it brings back vivid memories of uncertainty; fear for ourselves and our patients and wondering how we could continue to serve our patients who were already predisposed for isolation by the pure nature of hearing loss.  Never in our lifetime had we been asked, or in some cases told, to shelter-in-place due to a medical threat. The healthcare world was managing difficult questions of how we keep people safe while still being able to serve their medical needs.  The discussions were swirling in the media, in phone conversations with colleagues and within practices on what is considered “essential healthcare services” when a community is faced with a global pandemic?  Some classified “essential” as anything required to save a patient’s life; others considered anything that negatively impacts a patient’s quality of life as “essential care”.  As a medical provider that witnesses the impact on the overall health and wellness that even an untreated mild hearing loss can bring, knows that for most, untreated hearing loss has substantial consequences when the world is managing normal circumstances. Now to be isolated at home, without support systems like family and friends, created an environment where a patient’s only contact with the world is through a video or phone call, television, radio, and social media.  We argued that hearing care services were even more essential in everyday life, now more than ever, hearing was a person’s primary lifeline.

At that point, we started asking ourselves, how can our physicians and providers meet patients where they are: in the community, at their homes, and on their connected devices. Although some of these changes will reverse as the world feels safer and more comfortable, we believe that there has been a fundamental shift in the delivery care.  We already had digitally enabled care in some ways, through apps and our patient portal, we needed to expand our care delivery and inform our patients.  We ultimately learned to connect to our patients in new ways, through: telemedicine appointments, remote-programming schedules, drop-off services and curbside care; and we are not looking back. 

To make patients feel as safe as possible and meet the social distancing guidelines, medical professions were able to start providing telehealth visits to meet their healthcare needs in a time that being in an exam room with a patient was not “safe”.  In audiology, we can provide a vast number of services via telehealth, however, we must have our patients positioned to move to this type of care.  What do I mean by this?  Remote programming has been available in hearing instruments for quite some time, but not widely adopted due to licensing concerns as it relates to telemedicine and audiology.  But once again, COVID 19 created a window where prior telehealth regulations by insurers were loosened so patients could be provided healthcare as it was needed, and providers could receive payment.

In hearing care, we had the answer – remote programming.  Thankfully, the hearing instrument manufacturers had been incorporating remote programming capabilities for quite some time. That said, many of us did not wholly appreciate the effort until COVID hit unexpectedly. And even then, many of us were not fully prepared to deliver it to the bulk of our patients. Our practice had written hearing aid delivery guidelines that include activating any remote programming capabilities in the hearing instrument. So, in theory, as part of our clinical protocol, all instruments are to be set up for remote care services.  Guess what happened when the pandemic started?  We quickly discovered that for whatever reason, many providers had not initiated the remote capability.   As I investigated the reasons why it had not been done, the first reason was time, they didn’t have enough of it during the delivery of the technology to add another feature and counsel on it.  However, the biggest reason was they didn’t think the patient would use it.  And for the most part, at that time, they weren’t wrong.  Most of our patients set in-person appointments for their follow-up and on-going hearing care.  When we look back now, we just weren’t planning for a pandemic-like environment.  We had been delivering care one way, for a very long time; and only for extreme cases, like illness or distance, did we ever really use any type of phone consult, telemedicine visit or remote programming capability as a practice.  Wow.  We were wrong about adaptation when there are extenuating circumstances and other available care channels to receive help. 

This is where the Curbside Care Channel journey began for ENT and Allergy Associates of Florida.  To service our patient’s hearing instrument needs, we first had to have all hearing aids prepared for remote programming, which for most patients meant we needed their instruments in the clinic. However, at this time during the pandemic, we couldn’t have the patients physically in the hearing aid clinic, and thus, Curbside Care was born.  While servicing the patient this way, we could wear proper personal protective equipment, do the proper patient attestation, take temperatures, and mostly stay at the required social distance. Best of all, we could take the patients hearing instruments from them and prepare them for remote programming while they sat in the safety of their own car.

The next hurdle was figuring out how to inform our patients about the new way to visit the office. We wanted them to know that we were here for them.  The fastest way to engage with them was on our social media of course.  We went “Live on Facebook” on ENTAAF’s Hearing Clinic social channel and talked about the new way to visit the office, how the Curbside Care would allow us to assist them safely, what remote programming meant and communicated that they did not have to be our patient to get help. 

As providers, we focused on how we could manage the situation within the government guidelines and still find solutions that would meet the needs of our patients while protecting the staff.  Even though what we came up with may even seem outside-of-the-box, we simply focused on how to meet the needs of the patient by managing them “where they were”; and in this case, they were in their car. After all, some practices still utilize the care channel of ‘at-home’ care, and take care of patients where they live, we surely could be creative enough to manage care if they would drive to us.

Considerations when adding or maintaining this modern delivery channel:

1. Put a clinical guideline in place that requires that if remote programming features are available, they are activated at time of fitting.  Next, add this feature to your chart review process to monitor provider compliance.
2. Assess the parking spaces around the practice to determine best parking spots to assign as Curbside Services.
3. Assure you have adequate signage designated for the curbside area and that you have communicated to the patient how to notify the office when they arrive.
4. Familiarize and train support staff on services that can be provided curbside and how to triage patients between face-to-face care, drop-off service, remote programming appointment and curbside care.
5. Become familiar with all manufacturers remote capabilities allowing your team to manage patients that may have purchased from other locations. Understanding what is available also allows the practice to determine if there are other products that may meet the needs of current patients.  
6. Develop manufacturer specific checklists listing the required steps the provider must execute to enable remote programming capabilities in products.
7. Regroup with your providers and staff to discuss benchmarks around different care channels, talk about how they are doing, and what they are seeing with patient outcomes.  Remember, there is always a way to improve the experience for both your patients and the team that is providing the care.

Hopefully, we are turning the corner on this pandemic.  With that, many patients are still not comfortable being in the office, and for many, having to come into the office is a burden. We believe that Curbside Care and Remote Programming Appointments are here to stay in the world of hearing care.  Moving forward, we will continue to deliver hearing care in these newer channels.

Clinical trials have been used in the world of medicine for years, but now we are seeing an increase in trials that are more ENT-Audiology based.  An analysis of trial registration data downloaded from Clinical Trials.gov and utilizing administrative data from the Duke University Medical Center from October 1, 2007 to September 27, 2010 revealed a total of 1115 registered interventional trials assigned to otolaryngology.  Of these, head and neck cancer trials predominated.  But what is happening in this space in 2021 is nothing short of an explosion. At the time of this article, there are 797 current clinical trials in the hearing loss space as listed on Clinicaltrials.gov.  Although head and neck cancer trials are still leading in number, there is a significant uptick in trials for new pharmacological treatments & medications for sensorineural hearing loss, age-related hearing loss, tinnitus, and dizziness just to mention a few. There are also a number of ongoing FDA studies related to different devices used in treating hearing loss.

Our practice is currently involved in 14 clinical trials ranging from procedure trials to medication trials.  We have a clinical trial team that finds trials that may interest our physicians and providers, presents them as opportunities for the practice and then applies to the study. There are several steps from the time of application to when a site is accepted for participation in the trial. Each step of the process builds on the other until subject recruitment can begin. Look for our upcoming article on the Business of Clinical Trials.

As an audiologist, I believe some of the most exciting trials today are the studies investigating restoring the cochlear synapse.  It is more recently believed that when the cochlear synapse is impaired, it directly impacts a person’s ability to understand in noise.  This is supported in research on hidden hearing loss. This article discusses hidden hearing loss at length; the authors suggest this type of selective neural loss may be the physiological basis for many of the cases of hearing disability with a normal audiogram.

If you have been performing audiological testing on patients for any period of time, you most likely have come across a patient with a similar story. A patient presents with a concern about their hearing, you perform a hearing test, and everything appears to be within normal limits.  If we weren’t performing speech in noise testing at the time, did we tell them they had normal hearing? did we miss them altogether? I think about early in my career where we assured patients, as did our physicians, that their hearing was “within normal limits”, but was it really hidden hearing loss that went undiagnosed because the current research hadn’t suggested it existed yet, we weren’t performing an expanded standard battery on all patients, or we simply weren’t asking the right questions?

As we know, speech-in-noise testing is often not standardly performed, unless it is tied to a larger work-up like a cochlear implant assessment, an auditory processing disorder battery or part of hearing aid verification. Today, providers have the opportunity to dig a little deeper when the patient’s primary complaint is specifically related to difficulty understanding in noise, and their hearing is within normal limits.   In this situation, hidden hearing loss could still be missed without pushing beyond the basic audiometric testing. Now that the clinical trials and research are focused more than ever on hearing loss and other audiologically related symptoms, we need to become even more vigilant by consistently managing patients with robust patient history and expanded standard diagnostic practices.

Within our clinical guidelines at ENTAAF, the Quick Sin is included as part of our standard audiological battery, and still there are times where it isn’t done.  It is true that it takes slightly more time, and sometimes that makes it difficult to keep schedules on time. We find that performing the QuickSin or the Words in Noise (WIN) test adds about 3 minutes to the testing battery.

As audiologists, one of the most important things that we can do is to take the lead in educating the other medical providers that are involved in managing our patients with hearing loss.  When we provide them with peer reviewed articles that support the benefits of adding this into our regular battery, it better aligns our recommendations.  The audiogram has been thought by many to be the picture of what is happening with our patients hearing, but the truth is, we are finding that the basic audiologic battery used in most practices may not be robust enough to tell the whole story.

Listed below are a few things discovered in this journey to gain a better picture of our patient’s hearing health. By adding speech in noise testing to our clinical battery we have seen a number of benefits. 

The additional test:

1. Assists patients in understanding the complexity of hearing speech in a noisy background.
2. Allows us to quantify the degree of difficulty that patients are experiencing when listening in noisy environments and compared against normative data
3. Presents a testing environment that mimics where our patients complain they have the most difficulty, in noise.
4. Provides insight into those that end up having thresholds within normal limits but still feel they have significant difficult with speech in noise environments.
5. Gives us a baseline of performance to assess the benefit and project outcomes for the recommended aural rehabilitation programs.
6. Provides a robust group of patients to access information on speech in noise performance, allowing us to participate in clinical trials surrounding cochlear synaptopathy as well as opens up other clinical trials that involve hearing loss & audiological testing.  

If your practice location has been involved in clinical trials, then you know that there are several considerations before adding this service into your practice. Look for our upcoming series on the Business of Clinical Trials.

Diabetes and hearing loss are two of America’s most widespread chronic health concerns. More than 34 million people in the US have diabetes, and an estimated 34.5 million have some type of hearing loss. Those are large segments of patients, and it appears there is a lot of overlap between the two groups. 

Studies continue to reveal a correlation between diabetes and the increased risk for hearing and balance disorders. A recent study found that hearing loss is twice as common in people with diabetes as it is in those who don’t have the disease. What is even more alarming is what may be happening in the prediabetic segment. Of the 88 million adults in the U.S. who have prediabetes, the rate of hearing loss is 30 percent higher than in those with normal blood glucose. Often we ask patients about their history, and if they have diabetes may be in the list of questions we run through; however as providers evaluating a patient’s hearing and balance, it’s important to dig a little deeper. When is the last time we inquired about prediabetes? And on top of a more robust history, the more we understand about the basics of the disease, the better we will do as we manage their care over their lifetime. 

Blocking and tackling – understanding the basics of Type 1 & Type 2 diabetes.

Type 1 Diabetes

So, what is important to know out of the gate about Type 1 diabetes? Type 1 diabetes happens at every age and in individuals of every race, shape, and size. Basically, the key message is that in type 1 diabetes, the body does not produce insulin. The body breaks down the carbohydrates we eat into blood sugar, called blood glucose, and uses for it for energy.  Insulin is a hormone that the body needs to get glucose out of the bloodstream and into the cells of the body, where it can do its work. This condition can usually be managed with a lifestyle of proper diet and exercise. Insulin therapy and other lifestyle related treatments and long-term habits can lead to successful management of this condition.

Understanding Type 2

Type 2 diabetes is the most common and instead of not producing insulin, the body doesn’t use insulin properly. Type 2 diabetics can sometimes manage their disease with healthy eating and exercise, others more often, patients require medication or insulin to help manage it.

When managing a patient with diabetes, there are often a lot of players on the field.  The patient is the most important one on the team, as they are responsible for new habits and sometimes a new medication to successfully address the issues.   As a provider, getting to know the other players, communicating and collaborating on care is really important to the team’s star, as the more support a person has, be easier it is to stay on track.

Let’s get to know the different kinds of health care providers who can be part of the diabetes management team.

These can include the professionals listed below, but keep in mind, this team is broad. Talking with your patient to understand who is involved in their care is key to getting the entire picture of who is in the know, and helping with the overall management of your patient’s health.

• Primary Care Provider: the general practitioner physician or mid-level provider such as a nurse practitioner or physician assistant provides the routine medical care, including physical exams, lab tests and prescriptions for medication.
• Endocrinologist: this physician specializes in diabetes and other diseases of the endocrine system, when things get tough, they call in the big dawgs.  This team is the specialist.
• Ophthalmologist or Optometrist: Just as hearing is impacted by this disease, so are the eyes.  The medical physician or Doctor of Optometry both can play a part in the diagnosis and treatment of patients and any related eye diseases and disorders.
• Podiatrist: The foot doctor jumps in when circulation to the lower extremities is impaired.  The podiatrist is trained to treat feet and lower leg problems.
• Pharmacist: Everyone has a job here; the local pharmacist often is the one who sees the big picture when it comes to patients and their medications.  They keep an eye how they interact with each other.
• Dentist: Diabetes impacts our oral care too.  The patient’s dentist is an important player, keeping tabs on our patient’s teeth and gums.
• Registered Nurse: Often there is an RN that is overseeing chronic care management and coordinating the patient’s visits to multiple providers.  They can really make the difference for our patients and asking if there is someone in the primary care office that provides an extra hand is a good habit to get into when taking this patient’s history.
• Registered Dietitian: Being an expert in nutrition, the registered dietitian an important part of the team.  They are often advising our patients about the best foods that help manage blood sugar.
• Certified Diabetes Care and Education Specialist:  Certified Diabetes Educators have extensive training and experience working with people with diabetes.  They are coach our patients about from manage the things you need to do to take care of your diabetes, in a way that fits with your daily life, routines, environment and family dynamics. To work with an expert in a diabetes education program recognized by the American Diabetes Association, visit diabetes.org/findaprogram or call 1-800-DIABETES (800-342-2383) to find a program in your community.
• Mental Health Professional: This person may be a psychiatrist (MD or DO), psychologist (PhD) or clinical social worker (LCSW or LISW). These professionals can help you deal with the day-to-day challenges of living with diabetes as well as more serious emotional issues. Be sure to work with a mental health professional who understands diabetes and the medicine and insulin you are taking that may affect your blood sugar.
• Fitness Professional: A physical activity specialist may be an exercise physiologist, personal trainer or physical therapist. These professionals can help you find exercises that are safe for you, and ensure you get the most out of your exercise program. Be sure to work with a fitness professional who understands diabetes and the medicine and insulin you are taking that may affect your blood sugar.
• It is important to choose diabetes care team members who can provide the level of support you want and provide help when you need it. The more information you can give when you get help, the easier it is for someone to assist you. Be sure to write down questions and concerns to bring with you to your appointments.

Check out the CDC brochure that talks Ears and Diabetes – and suggests ways to prevent the negative outcomes of hearing and balance impairments. Download a quick reference here! https://www.cdc.gov/diabetes/pdfs/library/Diabetes-Ears-h.pdf

When it comes time to seek medical care for any ENT related issues, there are some key factors that everyone considers: convenience, experience, skill and expertise, and bedside manner to name a few. What many are less likely to consider is whether you should see a physician or a physician assistant (PA). Many patients are pleasantly surprised to learn the full scope of practice that PAs are able to provide and the increasing number of benefits they bring to healthcare.

Physician Assistants are Medically Trained

The key difference between medical training of a physician and a physician assistant is time. Typically, doctors complete four years of medical school, followed by an internship and residency. PAs finish their training in two years. During that time, they experience many of the same scenarios as their medical doctor counterparts, including surgical procedures. In addition, many PAs choose their career path following a job or training which has already given them experience in the medical field, such as paramedic. In Martha’s case, as you’ll learn, she chose the PA path after completing medical school in Colombia.

Let’s meet Martha Botero-Rivera, PA-C. Martha is currently a fellow member of Florida Academy of Physician Assistants, the American Academy of Physician Assistants and The Society of Physician Assistants in Otorhinolaryngology / Head & Neck Surgery. She brings to the practice over a decade of experience delivering “patients-first” medical care in various clinical settings in the U.S. and Colombia.

Tell us a little about yourself, which PA program you graduated from and when you graduated.

I’m originally from Colombia, where I completed medical school and worked as a primary care physician. After I moved to the United States, I passed the U.S.medical exams, and obtained the Foreign Medical Graduate Certification in 2014. I graduated as a physician assistant from Miami Dade College, obtained the Certification from the National Commission on Certification of Physician Assistants and joined the practice of Dr. Nathan Nachlas, MD at ENT and Allergy Associates of Florida shortly after graduation. 

I was one of the first graduates to complete The NFO Certification Program for PA Excellence in Otolaryngology/Head and Neck Surgery in 2019. This post graduate program was created by Dr. Nathan Nachlas, MD and Jose Mercado PA-C with the purpose to serve as the foundation for lifelong learning in the ENT diagnostic process. 

What is your current specialty? Why did you choose this specialty?

My specialty is otolaryngology. I chose ENT because the field offers a unique setting. The scope of the field is incredible and encompasses principles of various specialties including primary care, infectious disease, oncology and plastic surgery to name a few.  

What type of environment do you work in (hospital, clinic, administration, or a mix)?

My employment is in an office setting exclusively; however I do support the post-anesthesia care unit (PACU).

What is your schedule like? Do you work Monday through Friday, weekends, holidays, night shifts?

I work Monday to Friday from 8 to 4:40, but there is always extra work to do after hours, so I typically stay in the office till 6pm. Thankfully I do not work weekends or holidays.

Do you take call?

I don’t have to be on a call round with the hospital, which is nice. We do take patient phone calls during the weekend for urgent matters. Most of the time the call is triaged by a medical assistant. If there is something that they cannot handle, then we take care of the patient call.

Describe what a typical day like for you?

I usually start my day at 8 am, unless it is a surgical day were I am assigned to help in PCAU, then my day starts at 6 am. On an office day, I see an average of 10-15 patients. They come with a variety of ENT complaints and we also see post-operative patients.

How autonomous are you, what types of things do you involve your supervising physician for and what do you do on your own? Is this typical for your specialty or more specific to your situation?

I’m 90% autonomous. I usually involve my supervising physicians if there is a case that surpass my knowledge or requires surgical management. I believe this is typical for my specialty.

Do you currently participate in any administrative tasks or have a leadership position, formal or informal? Do you think these augments or hinder your other responsibilities?

I do not participate in any administrative tasks.

What advice would you give to a PA who is considering working in your specialty?

Learning about ENT on my own was and continues to be challenging. Therefore, I strongly suggest doing a postgraduate program in ENT or enroll in a fellowship for PA’s in ENT.

What is the one thing you wish PAs in other specialties knew before calling or referring to your practice?

I wish they had a better understanding of how to properly examine the ears.

Is there anything else you’d like to add?

I will say to the PAs that want to work as ENT PAs, they should look for any opportunities to learn. For example, continuing education is a great tool during the learning process. It is an investment of time and sometimes money into improving yourself. It will make them more qualified for advanced work and increase confidence in the evaluation of patients.

A Tale as Old as Time.

How many times have you seen a patient that told you they went to the ER because they lost their hearing?  Had a change in hearing? Or were dizzy?  When they finally arrive at your ENT practice, and you ask what was wrong, they report they had a middle ear infection.  However, after the round of antibiotics and decongestants, they still feel like their hearing isn’t any better, so they thought they would follow up with the ENT physician. The majority of time, the patient has already waited several weeks or months before they decided to come in for the appointment. When they arrive, the ENT completes a simple TFT and finds immediately that the loss is most likely not conductive in nature.

So, it makes you think, are there other medical providers that could provide better patient care if they knew how to perform a TFT? 

In talking with a number of our otologists and general ENT providers, it’s a common frustration.  Many voiced that if ER providers had performed a simple TFT, they would have made a different diagnosis! They could have treated the patient for sudden sensorineural hearing loss, referred them more urgently and the likelihood of the patient regaining some, if not all, of their hearing would had been a greater possibility. 

So, let’s think about it from inside our own house – within the ENT practice. What is the benefit of the ENT physician and other providers doing a TFT when they have audiology available to them and they indeed intend to order an audiological workup?

I recently sat down with our neuro-otologist, Mark Widick, MD, FACS and posed the question: 

“What are the benefits of performing a TFT when you have an audiogram in front of you?”

” When I was at Vanderbilt, all the audiologists did TFTs as part of their workup. The TFT would help them understand if they might have a conductive component prior to starting the testing. It helped them pick what ear to begin in, sometimes what test to start with and also sometimes they would ask different or more detailed questions. Would this not help you have more confidence in your results, especially when they are not necessarily following the pattern of hearing loss that you expected to see?

As a physician, it allows me to confirm that what I see on the audiogram is consistent with what I am hearing from the patient and finding during my TFT testing. I’m looking for consistency for diagnosis and treatment plan.

By using multiple placement sites for a Weber; forehead, mastoid, and front incisors, typically with a 512 Hz tuning fork, you can again see the consistency or inconsistencies between the placements, which when dealing with bilateral conductive hearing loss with possible masking dilemmas, gives you added confidence!

Many times, the TFT will be the final confirmation for which ear I consider performing surgery on first, in the case of bilateral involvement, i.e., typically selecting the ear with the best bone line that I see on the audiogram and again has been confirmed with the TFT. 

Sometimes the things we do are more for the patient than for us providers. Many times, the patient has an ah-ha moment when I put a tuning fork on the mastoid or teeth and an ear that the patient considered “dead” or “of no use” all of the sudden can “hear”. This helps open them up to different treatment options, where they may have not been in a place where they would had truly considered them without the experience.”

As we continued our conversation, Dr. Widick asked me to put myself in his shoes, the shoes of the surgeon, and it quickly gave me insight into why they SHOULD be validating the audiogram.  If I was the surgeon, and there was a simple way to back up the results of the audiometric battery, which can reveal conflicting results particularly when there is disease, I would feel it was my responsibility to do so.  Also, as providers, we want our patients to trust that we are aligned as a team and working toward the most positive outcome possible. 

Ultimately, the physician performing the TFT had nothing to do with his trust in my ability as an audiologist nor was it a dispute that the TFT was a more scientific approach to the assessment and diagnosis of hearing loss.  More holistically, as a physician that is getting ready to take a patient into surgery, it was about knowing that he did everything to confirm that the results were aligned, and the procedure was truly indicated. 

Not every patient will need a TFT; however, for many it may be the final piece of the puzzle that confirms results and assures the provider that their medical or surgical treatment plan is the best path for the patient.  

A big thank you to Dr. Mark Widick for his time and insight.  Check out the “Under the Microscope” presentation for great information and discussion of the TFT.

About Mark H. Widick, MD, FACS

Dr. Mark H. Widick graduated from the University of Florida School of Medicine in Gainesville, FL in 1987. He completed his general surgical residency and otolaryngology residency at Vanderbilt University and completed a fellowship in Otology and Neurotology under Dr. Michael Glasscock at The Otology Group. Dr. Widick is Board Certified by the American Board of Otolaryngology.

Dr. Widick has served as President of the EAR Foundation of Florida and Delegate to the Board of Governors at the American Academy of Otolaryngology – Head and Neck Surgery.

He is actively involved with the American Academy of Otolaryngology – Head and Neck Surgery, the Florida Medical Association and the Palm Beach County Medical Society. He is currently the President of the Florida Society of Otolaryngology – Head and Neck Surgery. Dr. Widick has lectured at numerous conferences and has published in several medical journals. He has also served on the faculty of Vanderbilt University as a Clinical Instructor in the Department of Otolaryngology.

Read Dr. Mark Widick’s Bio