EPISODE 40

[INTRODUCTION]

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[00:00:48] DS: You're listening to On The Ear, an audiology podcast sponsored by 
SpeechTherapyPD.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical 
professor, and lifelong learner.

While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely 
intrigued by the many areas of audiology and communication in general. This podcast aims to 
explore the science of hearing, balance, and communication with a variety of experts in hopes 
of equipping you to better serve your patients, colleagues, and students. Let's go. We are live 
and On the Ear, brought to you by SpeechTherapyPD.com.

[OVERVIEW]

[00:01:36] DS: Even as the global understanding of hearing loss and its widespread impact 
continues to expand, patients continue to face barriers to their access to hearing healthcare. 
While policy and practice changes have helped to deconstruct some of these barriers, the 
COVID-19 pandemic only highlighted where so much work still needs to be done.

Fortunately, healthcare professionals across disciplines are working to better reach underserved 
populations through innovations in telemedicine and outreach. Today's guest is here to share 
how his work is helping to close that gap. Dr. Matthew L. Bush, MD, PhD, MBA easily the most 
credentials and degrees of any guest ever on the podcast, is the Vice Chair for Research and a 
professor in the Department of Otolaryngology-Head and Neck Surgery at the University of 
Kentucky in Lexington, Kentucky.

He holds the University of Kentucky College of Medicine endowed chair in Rural Health Policy. 
He earned his medical degree from Marshall University, School of Medicine in Huntington, West 
Virginia. He completed his otolaryngology residency at the University of Kentucky. He then 
completed a postdoctoral research fellowship and his otology and neurotology and cranial base 
surgery fellowship at The Ohio State University. He also completed a PhD in Clinical and 
Translational Science in 2017, and an MBA in 2020, both of them from the University of 
Kentucky.

His research is focused on hearing healthcare disparities. He serves as the PI of several NIH-
funded community-based trials to promote hearing healthcare access and utilization among 
underserved populations.

[DISCLOSURE]

[00:02:57] DS: Just a couple of financial disclosures. I'm the host of On The Ear and receive 
compensation from SpeechTherapyPD.com. Dr. Bush receives compensation from 
SpeechTherapyPD.com for his contributions to today's presentation.

[INTERVIEW]

[00:03:07] DS: All right, Dr. Matthew Bush, it's so awesome to have you. Your reputation 
precedes you in the best way possible and I'm so excited for you to be joining me. How are you 
doing?

[00:03:17] MB: I'm fantastic, Dakota. I am elated to join you and very thankful to talk to these 
topics, these issues. But to make a new friend and further work together towards addressing 
some of these challenges. Exciting and thank you for those kind words. All those degrees don't 
mean a whole lot in a pragmatic sense. I feel like there's an inverse relationship with the number 
of degrees that you hold, and how much you actually really know, practically. I feel like with any 
more learning, something else useful falls out of the back of my head.

[00:03:57] DS: Because there's a limited capacity. But I don't know, because the work you're 
doing too, is also Ð I mean, there's a lot of ways that you could approach disparities, and I think 
your degrees kind of speak to how convoluted this issue is, right? If you have your MBA 
business standpoint of thereÕs the financial impact in the financial limitations of disparities, 
you've got your MD, so you've got the more medicinal, physical impacts of this, and then your 
PhD, and more the research, and the more widespread population impact.

I think, you have the perfect setup. I think, there's probably plenty of room in that brain of yours 
to tackle some of these issues. I think, your research alone, your reference list is out of control. 
I'm so interested in what drew you to this topic specifically. I mean, was it in your MD? Was it 
when you were going for your PhD that you started to hone in on this topic of healthcare 
disparities? What led you to this point?

[00:04:51] MB: Yes. Well, there's no doubt that my academic degree pedigree is demonstrative 
of an immersive approach to try to address disparities because they're complex. They thrive in 
the pragmatic and the complexities of life from, like you said, the business, the medical, the 
research side of things, and we have to have different approaches.

But for me, it's really been a very organic and natural thing for me to pursue research in this 
field. I'm an Appalachian, by birth, by God and grew up in West Virginia, was very well provided 
for and grew up with means, with parents that were hard working and had access to good 
educational resources and good health care. WeÕre observant of basic things that their family 
needed for public health and wellness. The reality is, is that growing up in an environment, 
where rural life and rural communities gives you a sense of those that have and those that have 
not, and there's many other people who have grown up in an urban city and urban environments 
that may have had some similar connections and learning. They have had opportunities to excel 
academically and professionally. But still, their family, their friends face inequities and 
challenges in health care.

I think, growing up in West Virginia really gave me a grounding, if you will, in understanding the 
simplicity of rural life, the beauty of rural life, and sometimes the needs that are there, but yet 
also some of the fatalism that can occur in cultures of just dealing with disparities by saying we 
just accepted life is hard and there's not much we can do about it.

In medical school, those things were really impressed upon me. The most influential physician 
in my medical school career was a family practice doctor who made old school house calls out 
in the rural hills of West Virginia, would bring flu shots to invalid, housebound, older adults, and, 
really found himself, that I need to be out there and in the community. That really impressed 
something on me. Because I saw the joy that was in the providerÕs face and in his life and in his 
words. You can see it also in the patients that welcome that doctor like a family member to the 
front porch. Then, took a really sharp turn to residency as pursued to learn laryngology 
residency. I really felt the need to address and see the challenges as it relates to hearing health 
care.

Being a resident here at the University of Kentucky, which is in Lexington, Kentucky, right at the 
precipice of Appalachia, but still nestled in central Kentucky that's surrounded by very rural 
communities. Seen huge differences, let's say, in pediatric hearing health care. Those children 
that were born in and around the Lexington area, having ample access to care, and timely 
delivery of diagnostic and treatment options for hearing loss. Those coming from the more rural 
eastern Kentucky areas, not having the same opportunities and the same timing.

Then, that's just continued. As I've pursued, I realized, I want to pursue a career in academic 
research. I've done bench research and had some really great opportunities along the way in 
fellowship and early career for some more bench work. But my heart just kept driving back to 
what I've learned in my family reunions, in my medical training, but then also, in my own 
practice, of just getting back to where the greatest needs are in the community.

[00:09:00] DS: Wow. Yes. It sounds like it's really informed by a lot of different aspects of your 
life. But I think having that personal connection is probably Ð the fact that you can't really 
escape it, right? You check in with family, and it's okay, there's still work to be done here in 
these rural communities.

I'm curious, how much of Ð and we're going to dive into different disparities and different facets 
of that. But I'm curious how much in your work you've seen location, geographic location play 
into that? Do you feel Ð I can imagine that historically, over the course of medicine in our 
country, that geographic location has always been a limiting factor, and a cause of disparities for 
health care, right? I mean, if you can't get to where the care is, that certainly limits your ability to 
receive it.

I'm curious where you've seen that just from growing up to now, how different it is maybe in the 
town you grew up in or with family members that were even more rural. I also grew up in a really 
rural town in Virginia. I remember, I mean it was an hour and a half drive just to see the 
pediatrician that I saw. It was always a really big limitation to getting care there. But I know now, 
going home and visiting, there's a lot more populated Ð cities grow and spread. It's a lot easier 
to get to these things. I'm just curious about what you've seen, maybe on that personal level in 
terms of access to care for these rural populations through your time in your career?

[00:10:24] MB: Yes, thatÕs absolutely the truth as far as this very slow diffusion of care, even 
specialty care into rural areas, and sometimes, I'm shocked that I'll be in some remote rural 
location. I provide care in some pretty remote clinics that are a couple hour drive from here at 
the University of Kentucky. I'll see a patient in a restaurant or in this clinic, who come in, who got 
a cochlear implant. There may be no one else in the county that has a cochlear implant, but yet, 
here's a patient who was abled somehow, some way, to have hearing health care, not only with 
hearing aids, but has appropriate move towards cochlear implant or receiving implant, and yet 
find ways to get an implant programmed.

So, it has been interesting. But the geography is an issue. These are things that we do find in 
our research, that distance makes a difference in timing and delivery of care, and it influences 
the access and utilization of care. But there's a lot to the different places that are related to the 
culture and the community. That issue where you have the only Ð you're the only patient in the 
county, or in several surrounding counties that have a specific type of device, or a specific type 
of condition. It can be pretty isolating and that's a unique thing. Those people can be bright rays 
of sunlight to others that may have the condition because they can provide some personal 
knowledge of what they experienced and what their journey was.

But I think it's really interesting. To me, I use that phrase. That's what I've seen. It's just like, this 
very delayed release, and slow diffusion of technology and resources that will get to remote 
places, just the same way that iPhones could find their way anywhere on the planet, and even in 
the most remote area. It's just not going to be an iPhone next 2.0 or whatever, the most recent 
version of it. But nevertheless, the technology and these things can continue to be diffused.

[00:12:56] DS: Yes, they find a way into these places.

[00:12:57] MB: It's amazing stories, how these people can find a way through a connection, just 
an opportunity that they just seize.

[00:13:05] DS: I'm sure one of the ways that you're able to provide care into some of these 
places is via telemedicine and I know that's been one of the leading ways we've seen access 
improve over the last couple of years. But I had to give you a shout-out, because just brushing 
up on you and then also on a different project I'm working on personally. You had a paper on 
telemedicine for hearing healthcare. In 2019, it was published, so I'm sure you were working on 
that prior to 2019, way ahead of the curve, pre-COVID, with the telemedicine paper. I'm curious 
what got you on the track into looking into telemedicine for hearing care, and how you've seen 
that change since that paper?

[00:13:46] MB: Well, I guess in some ways, it's good to be ahead of the curve. My kid will be 
the first to tell you that dad is not a trendsetter. He's not going to set a trend that everybody else 
is going to follow. But honestly, telemedicine has been a love-hate relationship in my brain, in 
my research, and in my career. Because a bit Ð because of what we do in hearing healthcare, 
either as an audiologist or an otolaryngologist, there's a lot of examination, understanding 
nuances. There's diagnostic testing that's very operator dependent. Of course, surgical 
procedures. Those are hands-on things. So, there's limitations of what we can really do.

To tell you a funny story, when I was finishing my fellowship, I trained at Ohio State and was 
fortunate to train with some really great clinicians and scientist. My primary mentor, Brad 
Welling, has been a guru and in F2 and schwannoma research, and really has made a 
wonderful career of work in bench lab and translational work related to that. As I was 
considering a career in that too, I also had this passion and drive for health disparity research. 
Brad really encouraged me like, ÒThis is this could be a career. You could really pursue this.Ó 
There was a grant that came up about for me to apply, it was a collaborative grant between 
where I was training at Ohio State and UK, where I was coming back to join as faculty. 

I applied for this grant. I wrote it passionately and had this huge telemedicine component that 
was a part of it. The grant didn't get funded. I'm like, ÒHow can this be? I'm the golden child. I'm 
coming back from the promised land, into the motherland, and I've got all these great ideas. 
How could this not get funded?Ó Well, it wasn't that great of a grant. I mean, that's why it didn't 
get funded. But I went to go find the person. I wanted to learn who actually got this grant. It's 
this brilliant behavioral scientist, medical anthropologist, Nancy Schoenberg, who was ended up 
being a tremendous mentor. Became my primary mentor for my career development award with 
the NIH.

So, it was like my enemy became my friend and one of my greatest allies, because of 
telemedicine and my inability to articulate what to do scientifically. That was the challenge. I 
came in thinking, all right, what I'm going to do is I know there's a problem because I'm a 
clinician, and I know that my observations have to be scientifically valid. How could they not be? 
I'm just going to fix the problem right away and throw a tele-whatever, a tele-widget at tele-ABR. 
I'm going to put something in the community, and patients are going to flock to it, and we're 
going to do all these diagnostic ABRs remotely. The whole idea just became like, this is this 
giant wall of poor timing, and wrong questions, and wrong approaches to try to address the 
problem.

You need to understand the people, you need to understand the culture, some of the nuances 
before you immediately start to fix it with telemedicine. It's interesting that the pandemic has 
really pushed fast forward on everything that's telehealth related, and it's opening up amazing 
opportunities for the next century of healthcare for us to deliver different aspects of things 
remotely. But it's still complicated. It's still limited by so many different things, and my life 
lessons in my research have been like, don't just rush into telemedicine. Figure out how, when, 
and where, what's going to really contribute to sustainable work, that can really benefit health.

[00:17:55] DS: That's a really great approach to it. I really appreciate your humility and sharing 
that story, too. That's awesome to hear. I know that the process of being a researcher can be Ð 
there's a lot of evolution that happens over the course of the career. I think that's a really helpful 
insight for people who are maybe on that track. I know, I have a good friend who's been on the 
podcast a couple of times now who's out of Georgia. She's an audiologist there. We've had two 
episodes now, where the first one we recorded in 2020, where they had the funding obtained. 
They started a mobile audiology unit to get to these really remote parts of Georgia, to provide 
care. They were having a huge loss to follow-up rate on newborns, which was historically a 
problem in many states, and then with the pandemic has only been exacerbated.

She was really excited about this project. But the pandemic had just started, so they were trying 
to reorient and figure out what they were going to do. Then, we checked in about a year and a 
half later, and they had basically converted this original idea of going out into the communities 
into a remote tele-ABR system, and just listening to her process of working out the kinks.

I mean, you really would think with how accessible the internet is, for most people, it still isn't in 
a lot of these rural communities. I mean, it would be crazy to me to go into a metropolitan city 
and not be able to have Wi-Fi in just about every single building I entered. But the amount of 
hoops you had to jump through to find a health department that had Internet, that was open to 
guests, that they could bring in babies and train these minutes. Still in 2020, I think that was a 
2022 episode just so challenging. Just from the logistics side, let alone finding families and 
counseling them, and the manpower of it, but also, just the logistics of the Internet are still really 
hard to make accessible.

[00:19:44] MB: That's the truth. That's the truth. I mean, so many different levels. I guess, if 
they had a degree in telemedicine or telehealth, I guess that would be the next degree I would 
need to pursue.

[00:19:55] DS: Let's not get any ideas here.

[00:19:58] MB: Yes, for the cycle. I'm good. My family gave me an ultimatum, like, no more, 
you're done. Call it quits. But the reality is, that's the truth is that we take so many Ð we make so 
many judgment calls and presuppositions of what we think people know, and what we think they 
feel, and what we think theyÕre really facing. There's certainly logistics and the real material 
equipment, the technical challenges. But there's cultural challenges too. We have to ask 
ourselves, does the community really believe that, A, this testing is accurate? That, B, it's going 
to lead anything meaningful in the future, the quality of care, or important outcomes that matter 
to them for their child or their loved one? That's really important.

I think I've learned that, more than anything else, is that people Ð if people don't believe, the 
community doesn't believe in this intervention, this treatment option, this new opportunity, then 
it's going to fall flat. People in the community really have to believe in this. Even more than just 
believing in it, they need to feel like they're part of the solution, and they're partners in 
innovation, and partners in solutions in trying to address care. It's not and it can't just be about 
handouts. It has to be co-creation, co-innovation, and I've learned a lot of that the hard way. But 
thankfully, with some really bright community partners that give some very, very helpful 
feedback on directions that we follow.

[00:21:46] DS: That's really interesting. I don't really know that I've heard that perspective 
before, and I think that makes a lot of sense when you think of initiatives that have Ð they get 
the funding, they get all of their ducks in a row, but they didn't start with community buy-in and 
ultimately, end up failing. I'm curious what that looked like? I'm not sure if you've been a part of 
an initiative that took that approach. What does that look like? Is it being a part of, I don't know, 
town hall meetings? I don't know. I'm trying to brainstorm here. But what does that ultimately 
look like in getting buy-in from the culture, from a location like that?

[00:22:20] MB: The core axiom that we live by in pragmatic research, that it's involving health 
disparities, and health equity is about community advisory boards. Community advisory boards 
can look a lot of different ways. It can be composed of lots of different types of members. But it's 
really about giving a voice to people who are stakeholders and can play a role in either the 
success or the failure of your research, or your initiative, or your scientific questions, or even 
program development or clinic outreach, for example.

But gaining the perspectives of those different community members. It could be an educator. It 
could be a school superintendent, school superintendent or school board member. It could be a 
politician, a council member. It could be a parent. It could be a caregiver for an elderly adult. I 
mean, it really depends on the question in the community. But I think whenever we barrel head 
first into a community that has historically been marginalized and dismissed and say, ÒHey, 
here's the latest and greatest. Here's the solution.Ó We've come from the big city with this shiny, 
new, whatever. There's a lot of skepticism. We've learned a lot through some of the tragedies 
and travesties of racial bias and racism lived out before our very eyes, on news broadcasts, and 
through different scenarios in our society.

You look at racial and ethnic groups that have been persistently overlooked, and given these 
types of Ònew, fancyÓ resources and opportunities, to not be backed, and not be supported, and 
not to get any community input, they fall flat. The same is true in different groups geographically 
and perhaps rural communities, regardless of their racial or ethnic makeup, as that people have 
been sold a bill of goods year after year, decade after decade, promises that were made that 
were not kept. It sometimes can create a little bit of skepticism in the community.

If you get a Ð my advice when I talked about disparity research and pragmatic work is that 
everybody that's involved in this field needs to have a community advisory board. No matter 
what kind of research or clinical care you're trying to involve in, if you're not having a formal way 
to perhaps informally, but yet consistently get the input of community members and 
stakeholders, then I think we really do ourselves a disservice, and we're just not going to be 
grounded in efforts that we make.

[00:25:24] DS: Wow, that's so interesting. I definitely see the connection between those two 
concepts. I'm not personally involved in this initiative, but where I work, we're putting together a 
mobile unit to help reach. It started, specifically, for our pediatric cochlear implant patients who 
are driving four or five hours across the state, setting up this bus so that they only drive an hour 
or so or less, and we see several patients in a day. But now, the role of this bus continues to 
expand as we see the need across the state.

I'm assuming that the people involved in the planning of this our investing in these 
conversations with community members. But yes, I can definitely see how Ð thatÕs how you get 
the buy-in, is you have leaders of the community who are bought in and you're not going to 
convince these people. You're not these people. You're not in this community. But the people 
who are definitely will. That's a really interesting perspective on that.

I'm curious what other Ð we've talked about rural, or not just rural, but I guess, geographic 
location as a potential cause of healthcare disparities, maybe racial and ethnic differences as 
well. I guess, we haven't really dive too much into the history of that. But I know that that's 
historically, like, in one of your papers, you guys talked about that a bit too. What other aspects 
of care should we be considering when we're trying to address our own biases, or really look at 
disparities in hearing healthcare?

[00:26:43] MB: Unfortunately, it's an ocean of whenever you start to ask questions and start to 
look, then you sometimes get answers that you really don't want to get. Sometimes when I 
started to talk about disparities, or give a talk on the matter, I feel like, I am just nothing but 
doom and gloom. I am just telling everybody in this auditorium, or in this audience, how bad 
everything is, and it's not that bad, and that there are options, and there's hope, and there's 
opportunities. Collaborative work is moving and grooving and working to make differences.

But I think it's important to understand that disparities are deeply rooted in lots of different 
dimensions, and we can consider the factors that are influencing and allowing the propagation 
of disparities year after year, decade after decade, that come from these different domains of 
the social determinants of health. As a clinically trained otolaryngologist, a surgical 
subspecialist, I never really thought that social determinants of health would ever be a part of 
my daily dialogue or discussion. But if you care for patients, and if you care about where they 
come from, and where they're going, and what today is like for them, you have to be thinking 
about, this is more than just a clinical encounter that they are facing either barriers or facilitators 
that are rooted in these different domains of the health care access, and the quality of health 
care, and s the health domain.

Then, you've got educational access and quality, their background of what their education has 
been, their health literacy. You've got social-cultural influences, and imprinting that influence 
their behaviors, and where they go, and who they see, and who they're willing to listen to, and 
who they trust. You'll have neighborhood and built environment factors that influence that 
geographic place of where they live and health factors that might influence them, their socio-
economic position, whether there are financial resources and opportunities that are before them.

All these different social factors that are very different than the genetic causes and the biological 
causes. But they imprint every single patient that we see in every clinical encounter, or that are 
a part of any research study, and it affects people from cradle to grave. Throughout the entire 
lifespan, these influencing factors may either protect from disparities, or may propagate and 
make the disparity somewhat resilient and obstinate to change.

I think that's an important thing to frame things in terms of these different influencers. But when I 
think about the continuum of hearing health care, that it starts way before they are in the 
operating room for a cochlear implant, or they're in our office for a diagnostic audiogram, or the 
healthcare encounter with a specialist, perhaps, is involved. But their journey begins a long time 
before then. There is this knowledge, this self-awareness that occurs. There's interface between 
primary care providers where maybe hearing health care is discussed, maybe it's not. If it's an 
infant, whether they have access to high quality or meaningful EHDI services and consistent 
follow up through the EHDI system.

That entry into hearing health care is really important. For me, as a researcher, that's where I 
really think about. I've had to ask myself, ÒHow do I try to study the patients that never come into 
my clinic or never come to our audiologist?Ó We're not responsible for them, because they never 
got here. But I would argue against that. We, as healthcare professionals, hearing healthcare 
professionals, need to think about all the people in the outside, and how do we find a way to 
extend our circle or our sphere of influence, to bring them inside hearing healthcare and 
awareness and on the path. To me, that's a really interesting and important aspect of research 
that can help us ask some important questions, and then maybe get some meaningful answers 
that could lead to more efficient or effective entry into hearing healthcare.

The other important issue is where there are transitions, where you're moving from one clinical 
encounter to another clinical encounter. From diagnostics, to therapeutic. Or from one type of 
therapeutic, such as hearing aids into another therapeutic such as cochlear implants. Those 
transitions are places where you might consider an analogy of leaky pipes, where you're going 
to have patients that are lost to the system, and they don't want to pursue anything else. They're 
eligible, but not interested. Those are really important issues. That ties into that whole 
continuum of hearing healthcare, that disparities are just Ð there's so many opportunities to 
study and address it from a research standpoint.

[00:32:04] DS: Yes. I definitely like using this idea of hearing healthcare as a continuum to see 
where the gaps can occur, and having that as the basis. I see what you mean. There's this 
balance between the doom and gloom and the hope of it all. We've had healthcare in our 
country for a long time, but it seems like a lot of the issues are probably pretty similar to what 
they've been.

Where do you approach this? I think it's helpful, because not everyone listening is probably a 
healthcare disparity researcher like yourself. But they do either want to, maybe, at least ponder 
the impacts on their clinical care or start to consider solutions for their clinics. Things they can 
implement to help with that. When you think about how broad the influences are on this, where 
would you encourage someone who's starting out? Okay, there's clearly healthcare disparities 
where I'm working. I want to do something about it. I'll just throw, like a real-world example. So, 
where I am, working with pediatric cochlear implants, the no-show rate is just terrible. I see it 
more for the kids who come from rural areas. I see it more for low socio-economic status 
families. How do I help the people that I don't see? I can't talk to them and ask them, what are 
the barriers here? How do you approach those kinds of situations where it's not easy to get in 
touch with them, but you want to help address that problem?

[00:33:21] MB: The first thing and the most important thing is, don't throw up your hands and 
say, ÒI can't fix this.Ó Or, ÒI don't really know what the problem is, and I don't know what to do, 
and just to give up from the beginning, you have to just have an openness to acknowledge that, 
ÒOkay, as a clinician, I perceive there's a problem. But let's try to figure this out.Ó The first thing 
and you don't have to be a researcher to try to define or describe it. That's the first and the most 
important thing, and that's certainly where I started in my research is to say, ÒI need to be able 
to articulate that there is a problem.Ó I can't just go on my clinical intuition alone, or just 
interesting heart strings, pulling stories of a child or a patient who was delayed and didn't get 
their care.

But I need to find out somehow, some way to use data, the power of data to tell a story. It 
doesn't necessarily have to be published research literature. I mean, we can go through our 
EMRs with much more efficiency these days, than we could with our old chart system and have 
to look for no-shows or not, or some of these old scheduling systems. I think we're a little bit 
more efficient as far as EMRs. But if we can define and describe, okay, there is a population, 
maybe a racial group, an ethnic group, a cultural identity group, or individuals from a certain 
geographic region of our city, or of our state, that are not getting the resources, begin to use 
some data to define it.

Why that's important is because data can change opportunities. Data can open people's eyes 
to, there's an issue here. When we're talking about health systems, people see those no-shows 
as, unfortunately, as dollar signs. Sometimes administrators may not care as much about the 
outcomes that we care about, language development, or social isolation, cognitive load, or 
cognitive decline. Those things are maybe meaningless to certain administrators. But if you can 
connect it to lost opportunities, or loss of financial resources, then sometimes it can then open 
some doors for discussion of what are we doing programmatically to be able to connect. 

Because we learned this in academic institutions, is that not all people learn the same way, the 
way that we communicate with our learners, certainly with our patients. There's different means 
of communication that's more effective than others, and we might need to be able to reach out 
in different ways to schedule appointments, or to maintain follow-up visits, or to have patients 
pursue that recommended treatment, through some different resources and support than we 
might think in our brain.

Again, it starts with acknowledging that I think there's a problem, let's get objective about it and 
find some true data that will describe or define the problem, and then let's use that to try to 
identify and partner with perhaps our local team, as well as maybe members in the community, 
again, that get that community advisory board comes up to the forefront again. Then, devise 
and develop maybe some pilot or test programs that could be able to move the needle in the 
right direction. You don't have to fix it all. But to do nothing, is really Ð is giving into the problem. 
Do something is essential.

[00:37:06] DS: That was just so practically helpful. I really appreciate you breaking that down. I 
think anyone out there who is struggling and feeling the weight of the patients, you're not 
reaching. I mean, I really think that's just a really practical way to approach that and I really 
appreciate you sharing that so clearly.

Tell me a little bit about your current caseload. I know you are a practicing physician. You're 
probably in the operating room and providing clinical care, and then, you've also got your 
research going on. Then, in the back of your mind, the patients who aren't showing up and what 
you can be doing to help with those disparities. I'm curious what your approach to clinical care 
looks like with the background of all of these things that you bring into clinic with you?

[00:37:44] MB: I'm so fortunate. I feel like I've got my dream job to be able to see patients with 
about half of my time, and the other half of my time be devoted to funded research programs. 
It's a dream come true. They really do synergistically work together and energize each other. A 
day in the clinic, a full day in the clinic, even like today, I was in the clinic seeing patients all day. 
It's a tiring day, but it's also energizing in a way to know of the human interaction and 
connections that are made, the opportunities to speak some truth, or some opportunities and 
some clarity into the lives of people who've trusted me with their time and their ears. That's 
meaningful.

Jumpstart some research ideas and what we do through some of our research conversations 
jumpstart, then an excitement to get back in the clinic. It's a good thing. I've got an attention 
span problem to be jumping from one sphere to the other side, other spheres. But to me, they're 
not all that divergent. They're really very similar and they're meant to connect. That is a key in 
my life for not only joy and happiness in my work, but also sustainability of just not being burned 
out. Finding value, finding purpose.

But I will tell you that, the more that I've been involved in this disparity work, not only 
quantitative research to define and describe problems, but qualitative research where we 
actually ask open-ended questions, and then we shut our mouth, and then listen and let patients 
really describe these barriers or challenges, whatever that research project is trying to address. 
I find that it really builds my sympathy, my empathy, my humanity toward my patients. I feel not 
inconvenienced. I don't feel like, ÒOkay, hurry it up. You're taking too long to describe your 
dizzinessÓ, but trying to just be a very empathetic active listener. That's really important in this 
physician-patient trusting relationship.

I feel like, disparity research has given me a bigger heart and deeper passion for my patients to 
be an advocate for them, regardless of their means or their opportunities, and then just to really, 
listen well to them. That's been important. As I've gone throughout my career, I want to get 
better at what I do. I want to be a better listener. I want to be a better surgeon. I mean, we 
always want to continue to improve and hone our skills. But disparity work for me has been a jolt 
of humanity that keeps me grounded with them.

[00:40:37] DS: I can see how that would be the case, right? You get to hear these true stories 
of the limitation. Like you were saying earlier, a lot of the time, we can't know as much about the 
disparities, because those are the patients we're not reaching. But with your research, those are 
the people you're learning from, and you get to take that right into the room. That family that 
drove for hours and had a broken car and all that, I mean, that just means so much more when 
you come into it with the perspective of seeing the bigger picture, right?

[00:41:02] MB: It's so easy to get cynical, right? We're so quick to say like, ÒWe had this three-
hour cochlear implant surgery scheduled today for 7.30am, and you didn't call us until this 
morning. What's wrong with you? Now, I got to wait around for three more hours and hope that 
the next patient shows up.Ó Or, ÒWe had this sleep-deprived ABR, and this baby slept the whole 
way in the car and won't get this ABR. We got to cancel it. I mean, this lost opportunity. We've 
got a lost dollar symbol.Ó How quickly we get so cynical. But realizing that there are so many 
things. I mean, perhaps that family didn't make it because they thought they would might be 
able to make enough money to pay for the gas, to get one way to Lexington to that appointment, 
and then maybe get back home. But maybe they just didn't make ends meet. I mean, they might 
have had to choose between food for their family, versus a trip for a clinical encounter.

How dare we think that this is a person whose Ð their sole existence is just to be an irritant to 
me. It's just a really shameful way that is very identifiable. We can all identify and know that 
we've had feelings like that. But pull yourself back and think in terms of like, ÒAll right, am I 
thinking like a human being? Or am I just thinking like an irritated, semi-burned-out clinician?Ó I 
don't want to live the rest of my life and my career being that burned-out person.

[00:42:31] DS: Yes. That's a great reminder. I really appreciate how you can pull this back 
down to Earth with that thing. I know, I found myself in that situation before, that mentality, and 
you're so right. When you do get to see them and you do get to hear the story and how much 
more that can help ground things, keep you from being cynical. Are you providing any 
telemedicine these days? If so, I'm curious, that first grant, right up to today, how you've seen 
that care shift over the years?

[00:42:59] MB: We do deliver some telehealth. We've had a pretty proactive telehealth program 
to reach some very rural clinics and Appalachia, here through UK Health Care, our healthcare 
and organization here as a part of the University of Kentucky. That's been a long-standing 
program that's been very active across multiple types of disciplines. Behavioral health and 
psychology and psychiatry, neurology, a number of services are very, very, very well for a 
decade and a half, two decades.

ENT, our department has been involved in some ways through some satellite clinics and have 
continued to provide. It's much more accessible. You don't need to go to a telehealth center, 
where there is a setup for this. But, I mean, any clinician, with a camera on their screen can do 
their telehealth encounter through Epic or whatever EMR system.

There is continued telehealth delivery. There's aspects of care and limitations of what we can do 
telehealth-wise. Those diagnostic appointments, especially for pediatrics, like ABRs, remote 
ABRs. These are things we've done some work in the area. Technology can be expensive. It's 
even more expensive to have good help and consistent health on the other end of the fiber 
optics or of the Internet connection. That's often where the challenge is, is finding the right 
partner in the community.

We've seen a number of flares, some bright bursts that faded as you lost a medical assistant or 
a community member on the other end, that we just couldn't keep a program sustainable. But 
that continues. For us, like I said, as I initially thought telehealth is the program, I think is more 
of Ð I think more of my research and intervention has been about how do you build trust in the 
community? And how do you get the community involved in trying to guide and direct entry into 
care, or support the transitions of care, and utilize resources that are already existing.

That's where we focus more of our efforts is less on the technology and more on the 
relationships and harnessing the power of local community, stakeholders who are advocates for 
hearing healthcare. That's really where we've landed with a lot of the interventional work we've 
been exploring over the last decade.

[00:45:49] DS: That's great. I think the grassroots approach to that is probably super effective, 
and a lot easier to maintain, than just a one-time pop up shop approach. What do you feel like 
big-picture policy changes could look like to help improve these disparities? I mean, I know 
healthcare disparities have been around as long as there's been healthcare. But with your 
background, both research and growing up in a more rural area, where do you see Ð I don't 
know. This is a vague question. But big picture, policy changes, either at a state or a national 
level that could, you feel, this is like, what do they call it, big sky idea making, right? What's 
something we could implement that you feel like it really reach a lot of people and make hearing 
healthcare more accessible?

[00:46:38] MB: When I think about governmental or policy changes, the big buy-in things that 
come from the unifying organizations of a nation, or of a population of people. It makes me think 
about global health, because where there are challenges of hearing healthcare delivery, nearly 
the entire continent of Africa with a few exceptions face immense disparities and access to any 
kind of hearing healthcare.

The EHDI programs that exists on the continent of Africa, you could count on two fingers, 
probably. So, it is Ð and what it takes in countries that maybe, low to middle-income countries, 
to have hearing health care move forward is an agenda. It is a priority, that until a nation, until a 
government, until a policy-creating body believes in the importance and will be willing to invest 
in hearing healthcare, it will never receive the funding. It'll never have the sustainability of the 
programs that are facilitated by policy support. That's the challenge.

While we might look at the United States and say, ÒWe're a lot better off, we're a lot further 
along than some of these low to middle-income countries throughout the globe. We've got 
mature EHDI systems. We've got opportunities for reimbursable services.Ó We've got a lot of 
gaps. So, I think, that's an important issue of advocacy and promotion of hearing healthcare on 
the macroscopic level on policy, is that we need politicians and we need governing bodies to 
acknowledge the importance of hearing healthcare on the state level, and on the national level. 

Now, what that will then hopefully do, and we have to be able to stand behind what we may be 
preaching for, because a lot of politicians will say, ÒShow me the data. Show me the research 
that what you're promoting, hearing screening, for example, in primary care, which isn't 
reimbursed, isn't coverable delivery of care. Or diagnostic testing, or hearing aid fittings for 
adults, you name it. The important things of hearing health care, they would say, ÒShow me the 
data that demonstrates that this is life-changing. It saves money. It saves lives. It improves the 
quality of lives, and it's improving.Ó

Everything about America is we lack a lot of data that really supports on a larger, very rigorous, 
generalizable scale. Some of the things that we proclaim is really, really important. The lack of 
that data is a factor that prevents driving transforming policy change. But that's what we need. 
We do need more data that really helps to support and anchor the value of hearing screening 
for example. I mean, this is where my passion is. ItÕs like studying those patients and addressing 
the patients, way before they ever would come to an otolaryngologist's office or a tertiary 
academic audiology center.

Getting that entry into hearing healthcare through just public health regular screening of adults. 
Our US Preventive Task Force lacks recommendations for hearing screening, because the data 
is lacking. We can't be angry about that. We say, ÒHey, what do we need to do to change that?Ó 
We know it's important for some policy-making organizations such as Department of Health and 
Human Services, through the Healthy People 2030 initiatives to define what are important 
prerogatives for health and the future. Hearing screen is a part of it, but it's really only a small 
incremental increase of what we would like to see change on hearing screening in adults.

I guess that long rambling preamble, itÕs me just saying, that data really does drive decisions. 
Data really does drive programs and policy change. I guess, that's why I have to continue in this 
field of research, because I feel like unless we keep continuing to study, published, define, 
describe, and show value of hearing healthcare in multiple different levels, then I don't know that 
anything will ever change.

[00:51:26] DS: Yes, I think that's a great perspective on that. It brings me back to, like I was 
mentioning before, a friend of mine in Georgia, the way they were able to get the funding for 
their mobile unit was actually through the Department of Education, because they took the time, 
they pulled the data, and they looked at literacy outcomes for children with hearing loss in their 
state, and they were able to tie that back to that loss to follow up right after the newborn hearing 
screening. These kids, they had a high loss to follow-up rate, and these kids are hitting 
elementary school. By the time they're in third grade, they're so behind from a literacy 
perspective that it was greatly impacting their state's test scores and quality of life for adults. 
They had to approach it from interesting literacy and reading, to get the funding they needed to 
help for hearing health care, which I mean, there is a connection, obviously, right? But that 
wouldn't have been my first thought.

[00:52:22] MB: Yes, that wouldn't have been your first research study, maybe if you just are 
thinking about it as an outsider, of let's just define whether they got an appointment or not, or 
the timing that they got their hearing aid or not, as a clinical outcome measure. But the 
educational matter outcomes really matter. Yes, if you if you got the right data, and you can talk 
to the right agency and the right organization, then some pretty exciting things can happen.

[00:52:51] DS: Yes. I feel like it's so much more understood by people. Literacy is a word most 
people understand. They understand reading scores. There's a reading score for students and 
for schools. It's a lot harder to explain auditory skills, and even language development, I feel 
like, is a pretty abstract concept to a lot of people who aren't in this field. But if you say, ÒThey 
don't know how to read.Ó People know reading level, right? There on a first-grade reading level. 
That terminology is so much more approachable for the general population that I totally see how 
Ð we have to think outside of the box and how we approach the impacts of untreated 
undiagnosed hearing loss if we're going to get Ð you're right, it's that public awareness, first and 
foremost.

Our country, we're fortunate that we've had EHDI programs for the last 20 years or so. But in 
other countries that are still developing, that's step one, is that public awareness of hearing loss 
and its impact. I think that's a great way to think about that in terms of, you have to start from a 
place where people understand the problem. You can't ask them to solve the problem if they 
don't understand the problem in the first place.

We're coming up pretty close to the end of our time here. But I did, as somebody who works 
almost exclusively with cochlear implants, I'm so curious where you're seeing some of the 
healthcare disparities impact your implant patients specifically? And maybe, what your clinic has 
been doing, if they're incorporating some of your research into how they approach clinic 
management or even just front office. How was your research informed, your literal cochlear 
implant clinical care?

[00:54:27] MB: As I said, where I shifted some of my focus intervention of like, how do we Òfix 
this problem?Ó How do we address it with interventional research or clinical trials? Shifting from 
the telehealth, tele-whatever to community-based interventions. One of the biggest things that 
we've utilized is a program called patient navigation, which itÕs a fancy phrase really, that just 
means a lay person who has gone through the same type of complex health care such as, let's 
say, a cancer patient who has navigated through chemotherapy and is a cancer survivor, may 
be employed or trained as a patient navigator to learn some issues and aspects of the logistics 
of health care and help people to make some connections as needed.

But this is like, a navigator from a cancer program gives back and helps another cancer patient 
navigate through their journey through care. We've studied that. We've published on that and 
pediatric hearing healthcare and looking that from a diagnostic standpoint, from failed newborn 
screen or referred newborn hearing screen from the birthing hospital, to use navigation to see if 
it influences the child having a diagnostic ABR and seen it to be immensely successful. We are 
studying that more on a larger scale, a state level now, but we're also wanting to study that 
academically from the diagnostic to treatment standpoint, either hearing aid and or cochlear 
implant in their continuum of care.

In a practical sense, we have learned from and utilized the principles of patient navigation, and 
have employed and utilized formal positions, such as someone that you might hire like a 
cochlear implant coordinator, for example. Who is someone who maybe doesn't have a strong 
background or history in healthcare as a medical assistant, or a nurse, or things like that, or a 
social worker, even. But someone who feels passionate about the topic and invest in them and 
say, ÒHey, you're going to be a very valued member of our team, and we want you to tell us 
what we're doing wrong, what we could do better. But also, to help us navigate these patients.Ó 

We have had hired, employed navigators through the form of a coordinator, as well as some 
other community support individuals. But also, even, had unemployed navigators. Not because 
we're cheapskates. But because they say, ÒHey, I just want to donate my time. If I can ever be 
of help for your patients and support them and answer questions, let me do that.Ó We have been 
very quick to influence, to utilize patient navigators, to help influence what patients know, what 
are their attitudes about cochlear implants, about surgery, and help them to stay grounded in 
the realities of what we can do and we can't guarantee. Then, also, just to help see them 
through and support them through the journey.

Nobody wants a patient who's eligible, who's willing and interested to fall through the cracks. I 
mean, we just don't want that to happen. We don't certainly want to force people or coerce 
people to do anything that they're not wanting or ready to do. But patient navigators, in a 
practical sense, have really improved our effectiveness, and efficiency at communication. To 
me, that is the first and most important outcome before we look at word recognition scores, or 
hint scores, or cochlear implant caseload numbers. Those are secondary, tertiary outcomes. If 
we're communicating well, then we're successful, and that's really important. That's got to be the 
most important part of our cochlear implant program.

[00:58:33] DS: Wow. We're actually in the process of hiring someone for a position like that 
right now. I think, that's a really great way to approach how you onboard this person, is you're 
going to be that community facilitator first. I feel like one of the common themes of our 
conversation has just been that buy-in aspect of things, right? If we're going to address these 
disparities, we've got to have buy-in from the patients, we've got to have buy-in from the 
communities that they're coming from, we've got to have buy-in from the legislators who 
approve funding. It's such an important thing to communicate these needs of our patients and 
the needs of our healthcare system in general, when it comes to hearing healthcare. Using your 
killed your cochlear implant coordinator as a communication facilitator with these families, letting 
them use their expertise when it comes to communicating with a population they're a part of, 
and how effective that can be. I think that's a great way to approach that.

[00:59:28] MB: We don't belong in communication sciences. If this is our business of dealing 
with communication, if we're all Ð if we're just about transactions. I mean, we can't be 
transactional, we've got to be relational. That is the heart of the issue and there's a lot of things 
that we don't learn, we don't listen to, we ignore about our patients that result in bad clinical 
outcomes, but also other bad communication outcomes.

[00:59:55] DS: Just so you know, you've dropped so many, like, put it on a poster, in a clinic. I 
don't know if you're coming up with these random, but you've really got a knack for it. They're 
really powerful things there. I'm trying remember the one you just said. We need to be not 
transactional.

[01:00:15] MB: We need to be relational, not transactional.

[01:00:17] DS: That's good. That's good. Put that on a coffee mug with an ear and an implant 
on it. I'm not even kidding. That's awesome.

[01:00:23] MB: I think that was an MBA class, just solely devoted to coming up with 
meaningless quips.

[01:00:30] DS: But itÕs meaningful. I could see how the class might have been meaningless. But 
no, these are helpful. These are what people take home. Speaking of taking it home, let's take 
this thing home. It's been an awesome conversation with you. I've really appreciated your time. 
If there's people listening who have more questions, or are just trying to get their feet wet in 
terms of addressing the disparities they're seeing in their clinics, in their communities, where 
could they get in touch with you?

[01:00:54] MB: Well, I would love to have interaction and communication, and collaboration has 
been a secret to success. So, getting lots of different perspectives. But email works great. My 
primary work email address is a good way to get a hold of me. matthew.bush@uky.edu. I'd love 
it. I love chatting about this. I would do it for free. I'm glad that I do get paid to do this stuff, but 
it's a passion of my life.

[01:01:29] DS: You've made that very clear and I really appreciate you taking the time. I'm sure 
the listeners are just going to love this. Thank you again. It's been a great conversation.

[01:01:37] MB: Thank you.

[END OF INTERVIEW]

[01:01:40] DS: That's all for today. Thank you so much for listening, subscribing, and rating. 
This podcast is part of an audio course offered for continuing education, through 
SpeechTherapyPD. Check out the website if you'd like to learn more about the CEU 
opportunities available for this episode, as well as archived episodes. Just head to 
SpeechTherapyPD.com/ear. ThatÕs SpeechTherapyPD.com/ear.

[END]
OTE 40		Transcript
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