EPISODE 25

[INTRODUCTION]

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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.

[INTERVIEW]

[00:01:36] DS: When a patient comes to see a clinician with concerns about their hearing, we almost always complete the tried-and-true behavioral audiogram. Does this person have aidable hearing loss? Let’s fit you with hearing aids, no problem. But what if that audiogram shows thresholds in the normal hearing range across the board, do we turn this person away? More clinicians are utilizing speech and noise testing in their standard battery, but what other information could be helpful for serving this population? Could fitting a hearing aid for someone with normal audiometric thresholds be an optimal way to treat their problems? 

Today’s guest is going to break it all down for us. Dr. Gail M. Whitelaw is a clinical associate professor and director of the Speech-Language-Hearing Clinic at the Ohio State University in Columbus, Ohio. She teaches coursework in Pediatric Audiology, Ethics, Tinnitus and Professional Issues. She’s a preceptor for AuD program at Ohio State and provides direct clinical services. She’s also the audiology faculty member for the Leadership Education in Neurodevelopmental and other Disorders, the LEND grant, a maternal and health training grant at the Nisonger Center. 

Her areas of clinical interest include auditory processing disorders or APD in children and adults, tinnitus and sound tolerance disorders and issues related to super threshold auditory deficit. Some of things we’re going to be talking about today. Dr. Whitelaw has been involved with leadership aspects of the profession of audiology across the board. She’s very prolific in her service. She was a past president of the American Academy of Audiology, past chair of the Board of Governors of the American Board of Audiology and the past president of the Ohio Academy of Audiology. She is a distinguished audiology fellow of the National Academies of practice.

All right. Hey, Gail. How are you doing? Thank you so much for joining me. This issue is pressing. It’s something no one’s talking about, but seems so important. How are you doing?

[00:03:23] GW: I’m doing good, Dakota. How about you?

[00:03:26] DS: I’m doing really well. I mean, so happy that we connected a while back. You had reached out about the podcast, I want to say like, I mean, months ago. This had to early this year maybe and we just kind of hit it off and then as we talked more, I saw you had, I think it was a post in one of the audiology Facebook groups about this specific issue and you basically said, if people are interested in more information, email me and I’ll send you like a list of articles. This is a very pressing topic. I had truly never heard anything about this before. That’s being totally honest. 

Reading through this research, I was like, “Oh my gosh! Why isn’t anyone really – I don’t know anyone who does this in their clinical practice.

[00:04:02] GW: That’s a great point. It’s funny. I’m so happy that you asked me to come and talk about this because this is a topic near and dear to my heart and it should be near and dear to the heart of a lot of audiologists because we need to think about how we define ourselves. I get concerned when we define ourselves as people who sell hearing aids. We have the right right now to be concerned about a lot of things that are happening in the profession, certainly over-the-counter hearing aids and direct to consumer hearing aids raise some flags about what the future might look like and how we might work with patients. But I’m always shocked that we have so many people who want our services and we don’t seem to look at their functional communication skills, the things that they come and present to with us. I’m really glad to have the opportunity to talk about that.

I listened to the last podcast about animal hearing and I think it’s fascinating, but my joke with my students has always, we spend more time thinking about animal hearing than we do for a lot of the patients that come to us and ask for our services and we say, “Well, you have a normal audiogram, and the audiogram said –” I have a famous line that says, “Audiograms don’t speak. Patients do.” I’m always very concerned about how we address that patient population. I’m thrilled to be able to be here and talk about that tonight.

[00:05:23] DS: Yeah. That amazing line one of yours made it in a previous episode on auditory processing disorders with Dr. Angel Alexander. If people want to go back and tune in, she quotes you at the end of that episode because that is really just such a powerful quote and a great reminder. Okay. That’s actually a great jumping off point. This population, who are we talking about here? I know I think the most obvious candidates would be someone with an auditory processing disorder, where we see auditory difficulties or hearing difficulties with a normal audiogram. But I know, when you all are developing this approach and you’re thinking about this patient population, it definitely goes beyond APD, right?

[00:05:58] GW: Yeah, it does, but I don’t even know what you call it anymore, Dakota. Because if you look at the research that’s come out that Doug Beck and his colleagues did such a great job of summarizing. When you talk to Dr. Beck, he talks about super threshold auditory disorders. We have lots of names for this over the years. I’ve been an audiologist for 38 years and I can think of things that have been – it’s been called obscure auditory dysfunction or King-Kopetzky syndrome. I’m not sure what it really is in terms of the name or what the best way to approach it. The research currently says a whole lot about a whole lot of things that we’re just learning about. If audiologists haven’t really thought about hidden hearing loss, this describes a whole population of people who again have that normal detection threshold, those normal audiograms, but they have significant difficulty listening in background noise.

One of the frustrations that many patients who get to us and I want to talk about that. You mentioned about speech and noise testing. That’s supposed to be a standard of care for the profession of audiology, but if you look at what the research tells us, about 30% of audiologists routinely do speech noise testing. There was some great research that was done by my dear friend, who is now deceased but I respected him so much and people still respect him, Carl Crandell. Crandell’s research was focused on a lot of acoustics, and classroom acoustics and how acoustics worked into people’s lives. But he also looked at some aging issues, and both of these things relate to his research, which says that, listening in quiet is a really poor predictor of listening in background noise.

When we start to think about it, if we don’t ever test people in noise and we rely only on their pure tone audiogram, only on their detection thresholds, we miss a whole lot. Hidden hearing loss is an area where – people define it differently, just like they do with APD and I get that. But hidden hearing loss is starting to reveal some interesting things about perhaps people who have had noise exposure. We traditionally were taught, “Oh! They have a noise notch at 4000 Hz.” That’s not always the case, that many people with hidden hearing loss demonstrate ultra-high frequency hearing losses, which we don’t often see or absent OAEs. It’s a really interesting – I’ve venture to say fun, but I guess I’m in audiology.

[00:08:30] DS: Those types are welcome here.

[00:08:32] GW: I know. I love those kinds of people. They’re my people. Looking at hidden hearing loss I think is really critical. I have an amazing firefighter patient who has – and we can talk about this some other time or later tonight. He has an amazing podcast called The 25 and I’m allowed to say he’s a patient. I’ve been on his podcast. He talks about hearing loss all the time. But we’re starting to look at populations like firefighters who traditionally or historically have a lot of noise exposure, but they also have a lot of chemical exposures. In working with him and we’ve got a firefighter study up and going here. We’re going to see that a lot more effects to the auditory system. I know you now are sorry you asked me this because I’m not going to shut up about it.

[00:09:18] DS: Not at all. Not at all. That’s why we’re here.

[00:09:21] GW: The firefighters, we’ve always thought, oh, they have noise exposure. Yeah, they do, but oftentimes, that doesn’t show up until they’re in their 50s on a traditional audiogram. But if you talk to them, they talk about how much their hearing and listening skills impact their jobs. They’ve got pretty critical jobs to hear effectively. That’s a huge population. I also work with a lot of people who have had traumatic brain injuries, which is probably one of my very favorite groups of patients to work with, because they want audiology. They’re so right to talk to us. If we don’t listen to them, and talk back and tell them what we know, many of these folks have lots of issues with tinnitus or with sound tolerance issues. But the main thing that they talk about and we’ve known about this for decades is how they have difficulty listening and focusing.

When we start to talk about things like cognitive abilities, and there’s a great thing that I want to look at if we have time tonight to say, “How do we look at cognition more effectively?” We know that executive functioning, where we bring auditory, and visual and learning information altogether. If the auditory system isn’t doing that well, it puts a stress on everything, so it affects quality of life, it affects the person’s ability to be an effective listener and learner. It affects all of that. Those folks with traumatic brain injuries have often not received appropriate rehabilitation. There’s probably as many myths as there are about anything happen in brain injury. I think that audiologists need to take a specific, at least part of a course in this and a medical audiology course, because it’s fascinating and it relates so closely to what we do and it’s so much broader than just having a temporal lobe fracture or a temporal bone fracture or whatever we might say. 

I know a lot of people are like, “Oh, yeah! They get a fracture, a skull fracture and it does this and it does that.” That’s a very small percentage of the patients that I see and to me, they’re easy to work with. Oftentimes, they either have a sensorineural hearing loss or they have a conductive hearing loss that resolves itself. These people that I’m talking about, I would call auditory long haulers and they really, really want what we have to offer.

[00:11:43] DS: Wow! That’s a great insight. Actually, one of our most recent episodes that just was released was with Dr. Julius Fridricksson. He’s a SLP by trade, but now he’s a PhD, he’s a researcher on aphasia and he’s worked a lot with people with TBI. Now, he actually just changed all of his research looking at the brain with COVID and he’s saying, if you’re working with patients who are COVID-19 recovered and are showing signs of brain fog or the idea of a COVID long-haul, he says, go to the TBI literature because the conditions present themselves similarly. I think you’re bringing this intervention to light for a population that’s historically underserved. Meanwhile, on the back burner, we’ve got a whole new wave of people who are going to be these COVID long-haulers who might need similar intervention.

[00:12:30] GW: I need to go and listen to that. I’m so glad you told me about that. I haven’t seen that episode.

[00:12:34] DS: It was just today. So yeah, you’re not behind at all.

[00:12:37] GW: Oh! Fantastic.

[00:12:38] DS: You’re not behind at all.

[00:12:39] GW: You know, one of the things I guess I would say to that too is, right now, I know there’s a lot of controversy around with the auditory symptomology as related to COVID. I also see a lot of people with tinnitus. Actually, this afternoon, we had a patient in the office whose tinnitus started with COVID. When we’re talking about this population, I think a lot of people think about people, “Oh! People who have tinnitus always have hearing loss” because we’ve got that myth too. I worked with a lot of people with normal audiograms and they have tinnitus. When we think about and I just am thinking about this out loud right now, to be really honest with you Dakota, I haven’t really put this together until what you just said. But for people who have tinnitus, it really affects them cognitively and it affects their listening.

I see teens, a lot of teens and younger kids, but teens with tinnitus. They’ll talk about how it impacts their attention and how it impacts their listening abilities and how it causes listening fatigue. Those are all things until I started really getting involved in that population with tinnitus, I didn’t really think very much about. They probably fall somewhere in this category too. My world for the past 30 some years has really been auditory processing disorders. I hate when people keep talking about the controversies, because we got to get over that and do something for these folks. 

According to research that’s come out, suggest that 26 million Americans have these normal hearing audiograms, but have listening concerns, listening difficulties. Christina Roup, my colleague here calls it HD, hearing difficulties. Other people call it SAD as I mentioned, that Doug Beck will call it, which I don’t think we should call it SAD. That’s a bad acronym for it. But I do think that there’s a lot that goes into this. When audiologists want to practice, my great cry out to our profession is, please let’s all practice at the top of our scopes. This is our area of expertise. We are definitely the highest authority when it comes to hearing and listening, but so many patients have come or come here, go to other audiologists do the same kind of thing that we’re doing an they’ll say, “I’ve tried to tell audiologists and all they say is, ‘Your audiogram is normal, isn’t this good news?’” 

I want to just point out to people that might be listening tonight, that if someone leaves your office and they feel strongly that they have an issue, they don’t stop looking, you guys. They keep looking. They don’t find it to be good news. I’ve got lots of stories and I’ll tell you one right now. The day that you asked if I would do this, I had done a remote care visit with a patient of mine who’s a couple of hours away from here. We had fit her with hearing aids, which is what the topic is tonight. She’s a really brilliant woman. She’s young, in her 30s. She believes that she had an auditory processing disorder for her entire life that she didn’t perceive herself as very smart, that school saw that she wasn’t – they always reinforced for her, “You have terrible attention. You’re just a lazy student.” She’s an IT director right now and she’s really good at what she does, but she’s always had poor self-esteem about her listening.

She’s always said that it’s been hard to connect with people, communicate with people. One day was complaining to her sister about this as an adult, this past year. Her sister said to her. “I have a friend who is a speech pathologist, I’m going to ask her what she knows.” This person, the speech pathologist in Ohio said, “Maybe you should call Gail and see what she has to say.” We brought her in for an auditory processing evaluation and not surprising to anybody who’s listening, certainly wasn’t surprising to me, doesn’t hear well in noisy environments. We were able to document that in the testing that we did. We offered her some mild gain hearing aids and put them on her and she thought they were okay. I’ve done a couple of remote visits with her and got her programmed a little bit better.

There were couple of things she was looking for. Social is really huge to her. She has noticed significant benefit at work and with people now wearing masks again, but her social life, she said that the hearing aids have been life-changing for her with that. One of the things she wanted to hear her sister when they go to the FC Cincinnati soccer games, because it’s really hard to have a conversation there in the stadium and that was something she did a couple of weeks ago. Was so excited about it. But at the end of our remote care visit, she said to me, “You have to promise me something. You have to tell other audiologists what you do and how we do this because this is truly life-changing.” 

I was a little bit taken aback by that, because I realized that her journey had been, many people had told her parents that there’s no such thing as an auditory processing disorder, that nobody had ever tested speech and noise, even though that was her major complaint. I don’t ever want to sound like, “Oh! Aren’t I the expert,” because I get the benefit of being the armchair quarterback. All these people had other tests done and it seems pretty obvious to me. Well, if you’ve done pure tones and it’s not working, what else do we need to look at? I really appreciate patients who come to us and this is such an opportunity for us as a profession. I just can’t even understand how people, their concern about bringing patients to the door. These are people who are beating down the door and they’re not worried generally about what hearing aids look like. Many of these patients tell me, “I would wear a satellite dish on the middle of my head if I thought it would help me.”

[00:18:15] DS: That’s a great reminder. You’re so right. This is a moment to – who else is going to be the expert here on this? I can’t think of another discipline that could really take the lead in terms of addressing these listening difficulties that someone can have. I just think for too long, we’ve treated the audiogram as the end-all be-all in terms of what requires intervention. But yeah, I love that story. It’s the perfect foundation for our conversation tonight.

I’m curious, when it comes to – because I guess, there’s – I mean, I shouldn’t say there’s a standardizes APD battery because not everyone uses the same APD. That’s a whole conversation for another day.

[00:18:51] GW: Yeah, that’s a long conversation.

[00:18:53] DS: But when we think of this population, I guess maybe, for example, maybe a TBI patient of yours, when they come in, history of TBI, they’re having difficulties. What does that test battery look like for you? What are you doing beyond pure tone audiometry that you find is helpful? Because one of the things I really took from a recent conversation I had with an audiologist who works with tinnitus patients is, sometimes just doing the test that shows something is wrong, giving them something to say, “Yes, someone is finally affirming this difficulty I’ve had for so long” can be so helpful. I’m curious, what’s jumping out at you in terms of testing? Is there any test specifically that you find as a must-have for all of these patients or is there a battery that you always use?

[00:19:34] GW: I don’t always use the same battery, but that’s a great question. One of the things that I like for adults and we can talk about fitting kids too, but one of the things I like for adults is a case history questionnaire that my colleague Christina Roup here developed called the AAPS, the adult auditory processing scale. It’s great and it really hones in on what the patient perceives their needs as. Then we always do speech and noise testing, but I rarely don’t do speech and noise testing. We can talk about lots of speech and noise, what people like and what they don’t like. I happen to like in adults the QSIN and in kids, the BKB-SIN. I like the adaptive part of that. It appeals to the science in me. But I think that the biggest issue for any audiologists is to do a speech and noise test. We use the R-SPIN here and I’ve also used the HINT a lot.

I think it’s important for us to create that as, if you did nothing else than bringing patients in and I’ll tell you another story that I think is really illustrative and also an important one because it changed my career in a lot of ways. I actually like some of the standardized tests like the scan and I know people criticize the scan. However, one of the things I think about, especially say one of the TBI patients. I have to compare apples to apples and so having something that has a standardized, I can look at somebody’s IQ score for example or their language scores for example and compare their auditory processing to that in a standardized way. I always tell people when they’re trying to create an APD battery, what do you do or how do you do for the consumer that you have? Who’s your customer? 

If my customer is, say, a physical med doc and he or she is trying to put together the bigger picture. It’s great to have that standardization. I also like the listen test, the LISN. I use Gaps-in-Noise pretty regularly. We’ve pulled some things from other test batteries that, like the VACD, I still use some of that testing material that was available a couple of decades ago, but I still find it very, very useful. I might pick and choose based on what the patient’s concerns are. I think it’s interesting about what you said about talking with the audiologist who works with tinnitus patients.

For many of these folks, their whole life has been, they’ve been told, “It’s all in your head because your audiogram is normal.” Well, I try to say to them, “Yes, it’s all in your head. I totally agree with that.” But even when it’s not, even if somebody doesn’t have an auditory processing disorder, we have the skillset to talk to them about other kinds of things and make appropriate referrals, because I think this is a huge area for us to have inner-professional practice. I might refer to a neuropsychologist. I had a patient in this morning and I will get into all of her details because that would take forever, but she was talking to me about – she’s 57 and she’s got a lot going on emotionally and auditory wise. She was talking about her cognitive abilities and how she’s losing things at the moment.

I don’t do a cognitive screening. I’m moving towards that, Dakota, I promise. But I think that’s an important thing for us as a profession to start looking at. But in listening to her, I said, “Has anybody suggested to you that you see a neuropsychologist?” She said, “I don’t even know what they do.” We had this lovely talk and as she was walking out the door, she was taking a neuropsych’s business card with her. That neuropsych refers to us all the time when they have normal neuropsychological kinds of things or maybe a little bit executive functioning, but the auditory system is really kind of popping up as an issue.

I think that when we talk about this, it’s looking at the whole person and also validating them when we can. This patient said to me this morning, “I would have to really be a lunatic if I wanted to make this stuff up.” I think we teach audiology wrong. I harp on this here. That one of the first things we talk about is pseudohypacusis or malingering. Maybe it’s different in different facilities. But by the time people get to us, they’ve already had a bunch a hearing tests and I’m a great believer that there’s ways we can figure out who malingerers are. These aren't the malingerers of the world. There’s such a rich battery of ways that we can test the auditory system, that I think when we do that, we learn a lot about the patient.

I’m a great believer that whatever auditory processing battery someone wants to use is defensible at this point in time. Mine is defensible to me because I like the way I can compare it to other kinds of tests and I like the science behind some of the things, like the Listen S. I really, really like that. I really like the GIN, because it looks at a very specific area and I think it was well researched. Those things go into my decision-making. But right now, my encouragement would be whatever auditory processing and testing people feel comfortable with, they should dive in and not wait until it’s perfect.

[00:24:55] DS: That’s really great advice. That a really, really great advice. I’m curious with some of these tests that might detect a problem. You said that goes into your decision-making. We’re going to break down a little bit here too. I’m excited to get into the hearing it aspect of this. But what information – honestly, this is one thing I’m struggling with here too. With a normal audiogram, I guess there is diagnosis codes like abnormal auditory perceptions. Are you using that diagnosis for these situations or like, first of all, how are you using these tests in your decision-making and then what kind of like diagnostic information is there?

[00:25:31] GW: In terms of coding, yes. There are codes for auditory processing disorders for sure. An abnormal auditory perception is definitely one of those codes. How we’re using the information is to determine what a long-term – I guess in a couple of ways. What a long-term treatment plan might be? Would that include something like hearing aids or a DM system? Would it include oral rehabilitation? I’m kind of hot on the Amptify program for these folks. I like that program a lot, but there’s not, again, we’ve left our roots as a profession and there’s so many great ways we can retrain the brain. We know that. I’m kind of a purveyor of apps on my phone that do auditory training. When I can’t sleep in the middle of the night, I’ll play with some of these apps, which is really, again, pathetic and nerdy, but it teaches me a lot.

Or what kinds of accommodations do people need in their workplace? Even things like having coworkers wear clear masks, that’s been a huge issue for this past year. What kinds of things are appropriate in the workplace to ask for accommodations? I know I’m focusing primarily right now on adults, but what kinds of accommodations are we going to ask for in the classroom? I’m always shocked at some of the kids that I see. Actually, I just got a thing for an IAP meeting today. That we see these kids with normal audiograms who maybe the classroom teacher is the one who identifies them and says, “This kid says what all the time.” We saw a kid last week, a delightful seven-year-old and his mom said, “I’ve known my kids.” She said, “I have three sons and all three have been identified as having dyslexia. This kid is different than my other two kids.”

She said, “When he was little, I kept taking him back to the doctor to say, he can’t hear. Every hearing test would come back normal and they wouldn’t find otitis media.” She said, “He can’t follow along. He has really poor pragmatic skills. He’s just not good at this. I keep telling them, he can’t hear and they keep telling me that I’m –” what we say, the things we say to parents I think we should be embarrassed about sometimes. Not just us, but the entire medical field. “Oh! You’re an overly protective mom” or “He’s the youngest and everybody talks for him” or “He’s a boy and boys just aren’t good listeners.” I find those kinds of things very judgmental and offensive personally. 

We put him in the booth and this is a kid who, he was just as sweet as could be, doing all the testing great and we gave him speech and noise. He looked at my graduate clinician and he said, “I can’t hear anything in this. This is terrible. This is awful. I can’t hear.” She turns to me, she’s like, “You think I set the test up right?” I’m looking at it, I’m like, “Yeah, the test is set up right. I think his ears aren’t the thing that are set up right, okay?” He just really had a lot of issues. This was only last week. Schools already contacted me about, “What can we do to help this kid in the classroom? How do we accommodate this?” Not every school district as anybody who’s done auditory processing knows is supportive of this. But I’m just really kind of I’m heartened when I see that people are getting better about saying, “What can we do to accommodate?” 

This is the long answer to what you asked, but I would take a two-pronged approach. One is, what accommodations can be put into place and then what treatments might actually change the brain? How do we make those changes in the brain from both an oral rehabilitation perspective and from a technology perspective that we know happen based on research?

[00:29:09] DS: Yeah, that’s great. That’s a really helpful, I guess like a roadmap for how we go from testing to what happens next. With that in mind, I think for a longtime, the common understanding was actually, “You have a normal audiogram, we’re not going to do anything.” Then from there, has shifted more to, “Well, let’s try a direct microphone system or an FM system” or “Let’s try some oral rehab, at least learn some communication strategies for your difficulties and noise.” Now, to some of the work you all are doing with fitting hearing aids, why incorporate hearing aids instead of some of these more traditional options?

[00:29:46] GW: Well, I know I told you the story of when we first started to talk about this, about the first patient whoever got me to do this. Because I went into this kicking and screaming saying, “I’m never fitting a hearing aid on a normal audiogram. That would be dangerous” and I would say all the things that I hear people say to me now and think, “Wow! I was there. I understand this.” I had a patient who had a traumatic brain injury in a dodgeball accident, a senior in high school. Dodgeball is dangerous in case any of you don’t know. If you haven’t seen the movie, it’s a little bit kind of dangerous and people get traumatic brain injuries from way less things, but she had a traumatic brain injury.

It was really upsetting to her, because she had a view that she was going to join the FBI or the CIA. In those days, like 20 years ago, they told her that her auditory system wouldn’t even pass the physical aspect of this, even before I saw her. She was kind of a lost young woman, really smart and really sad about what had happened to her. She came here and we did an auditory processing workup. I talked to her about an FM system in those days and she should do that. She was all gung-ho. She would do anything I told her to do and that was great.

We put an FM system on her and she was a manager at a fast-food restaurant. She came back and had the remote mic in her hand and said, “This thing is great if I’m in school. It works great, but it doesn’t really support my life.” I was like, “Oh! What do you need it to do?” She said, “I need it to be more flexible.” She said, “Let me give you an example at work. I can’t just hang this microphone while we’re frying French fries.” She said, “The place is really big and I need something on my ears and I need something more than this.” She said, “I’ve been thinking about this and I’ve been doing some research about hearing aids, and I think you need to fit me with hearing aids.” I looked at her and I said, “I’m not comfortable with that. You have a normal audiogram and I haven’t given this much thought. I know what I would do. I would do ear measures, and I would get medical clearance.” I was like talking myself through it. She’s like, “You know exactly what you do.” Here’s this 18-year-old telling me old audiologist what to do.

[00:31:51] DS: She’s [inaudible 00:31:51].

[00:31:52] GW: It was fantastic. I said to her, “Well, I really need to think about this because I’m not comfortable.” She looked at me in the eye and she said, “I thought you are my audiologist and I’m going to tell you something. If you don’t help me with this, I’m going to keep looking until I find somebody who will.” You can either kind of put up or shut up was the issue. I spent a lot of time asking my AP dear friends, and I spent a lot of time talking to manufacturers, and I spent a lot of time having friends challenge me to tell me that this was crazy and some did, most didn’t and we fit her. She was thrilled that her hearing aids were her graduation present. She went on to college and loved them. She was the start of something bigger for me, because she taught me, listen to that patient and don’t be afraid.

Getting back to the other part of your question. Hearing aids nowadays with all the bells and whistles, all the stuff that we can turn on, the directionality, the speech and noise kinds of features that just typical hearing aids have. And the fact that you would have to try really hard to damage somebody’s hearing with the hearing aid in this day and age if you fit it properly. Because I would say, I won’t say it’s impossible, but you would have to be – I don’t want to even say inept, but you’d have to not think about this very carefully. We do real ear measures on every person that we see. We spend a lot of time doing validation along with verification. We spend a lot of time looking at features. I can tell you, we have hundreds, hundreds and hundreds of people that we fit. I can go back and look at what they look like and they don’t look like they have noise-induced hearing loss.

I do have a terrible story of a young woman who we saw, who we fit with hearing aids as demos. I’m also very fortunate, I have tons of demos that I can put on people. If you’re going to do this, I would highly recommend finding a way to get some demonstration hearing aids in your clinic so that you’re not returning or whatever, but most of these patients don’t want to return. But anyways, this young woman has come to me, a college student, fantastic young woman, identified as APD, wanted to try hearing aids. We put the hearing aids on her, she loved them. But her dad told me that hearing aids were just too expensive, so he found some amplifiers on Amazon that he was just going to fit to her and you could do this. He basically didn’t really like me very much, but of course, I didn’t like him very much either and I loved –

[00:34:26] DS: That’s how that goes.

[00:34:26] GW: He told me that hearing aid were to effin expensive. That was his final word to me one day. I was like, “Well, you’re not paying for the product, you’re paying for the process and what we’re going to do to help your daughter be more successful in her college career and in her life.” We had that discussion. These Amazon things didn’t work very effectively, so they would keep dying and he was paying like $600 for a pair. I don’t even remember what they were. I didn’t have very much involvement with them. But she ended up getting hearing aids through a state program in Ohio based on the data that we collected. You can get paid for this too by the way.

It was interesting because she called me one day and she said, “Dr. Whitelaw, I got these hearing aids from this place, but do you mind taking a look at them. My ears feel really full when I have them in.” I said, “Sure. Why don’t you bring them on in.” When I looked at them, they had set the hearing aids the same way that we had set her hearing aids when we had normal hearing and she said, “I’m not sure my hearing is normal anymore. I feel like I’m in a barrel.” Guess what she had, a beautiful noise notch in both ears. I’m so convinced that it was because of these crazy ridiculous amplifiers.

If you’re an audiologist and you’re doing this and you’re controlling this and I know we could make a lot of arguments about that, that I’m speculating and all that. But I think I’m speculating based on appropriate information, because she talks about the same time and these things sounded too loud to her and what she liked about the hearing aids so she could control them. It’s really kind of a heartbreaking, I’m not looking forward to some of the stories we’re going to hear about over-the-counter hearing aids as much as I’m not afraid of them and I could be a fan of them in a lot of ways. I don’t know for this population that I would just like send them out and say, “Hey! Why don’t you buy some over the counter?”

[00:36:16] DS: That’s such a great point. I completely agree when it comes to over-the-counter. I see them as such a great opportunity, but my biggest fear is the wording of, for mild to moderate only. When I traditionally think of that, I worry about my patients who are moderately severe to profound who if I were to ask them when I first met them, “How would you rank your difficulty?” They’re like, “I don’t know. Probably like –” If I gave then the list of options, they’d say, “Maybe moderate.” They’re not realizing, no, you have – but what I didn’t think about is this group of people with normal thresholds who would describe their difficulties as mild to moderate, who then in the same exact way and then just have a very, very negative experience to the point where, yeah, I can impact well beyond just a negative experience, well beyond that. Wow! That’s a really sobering reminder of how these things come into play with each other. Yeah, thank you for sharing that.

Question for you. Okay. So you’re fitting them to target, love that. Best practices all the way, What are targets on a normal audiogram? Does NAL and L2 have targets for – I mean, I guess, technically, I fit hearing aids on people with sloping losses, with normal thresholds in some areas and there are targets for them. But I’ve just never thought about what that would look like on the real-ear screen if across the board everything was normal.

[00:37:33] GW: Oftentimes, we’ll add a little bit hearing loss. We’ll add like 10 decimals to the audiogram. It’s kind of an interesting look. You have to get used to looking at that real-ear screen, because it’s different than what you typically expect. But you know, one of the things we try to focus on is also soft speech and really thinking about that. We use that primarily to make sure you we’re not over driving the ear. That’s really the big issue with real-ear measures, looking at soft targets and then making sure that we’re not doing anything that looks like it could be over driving that ear at that point in time.

I’m a big fan of, we’ve got to do real-ear and all of that. If anybody wants the protocol that we use, I know we don't have time to go through. Anyways, there’s not a screen that I can be like, “Hey! Take a look at this.” We’re happy to share that protocol with anybody who wants it. We’ve used it pretty effectively here. Jodi Baxter who’s another one of the audiologists, that’s one of my colleagues here. Christina Roup and I have presented on this numerous times. Christina has a couple of papers that were published in the past few years that look at this. Real-ear measures is an important aspect.

I mentioned earlier, I really like to have medical clearance on these patients because I like to have physician buy-in. At first, I thought that was going to be a major like sticking point that physicians were going to be like, “What the hell is wrong with you? This person has normal hearing.” There’s always the, “This isn’t ethical on one hand” or “You’re just trying to make money off of hearing aids on the other hand.” I think when physicians have heard their patients lament about how difficult this is, and then they see the benefits from hearing aid fitting, it’s quite amazing how they get on board. When I talk to them, I’d say, “I’m asking that you say there’s no medical contraindications. I’m not asking you for permission for this. What I’m saying is, is there any medical reasons this patient can’t wear hearing aids.” They’ll be like, “No. No.”

The first kid that I had that I wanted to do this with, probably not the first but the most – one of the kids that was among my first. I have this pediatric otologist that I adore and I think he and I have a great relationship. I called him for this APD kid and said, “I’m calling – I usually go to the pediatrician or the PCP, but I’m calling you because I want to bring you into my little fold here, my cockle of people who are willing to do this.” He said to me, “Darn you, Gail. If you damage that kid’s hearing, I’m going to come and get you.” I said, “I assure you, I will not damage this kid’s hearing.” Now, he’s one of the big proponents of sending kids our way when they see them where he works where they have APD. He works at a hospital where people don’t do this. He’ll send me kids all the time and say, “Can you help us with this?” He’s a great believer because he’s seen the benefit of it.

Going back to my kid that got me involved, like the 18-year-old that got me involved in this. Remote microphones are fantastic, but they don’t – you don’t get any benefit unless you’re using the remote mic. A lot of people like the flexibility of having that sound there all the time. They like the flexibility of wearing a hearing aid. They like the flexibility of having say, if we’re talking about Oticon hearing aids for example, having a connect clip attached to it. They like being – a lot of people with auditory processing issues aren’t good on the telephone. They don’t get the visual and I guess, nowadays, there are so many visual ways you can use that. We don’t always use that.

But having something that direct streams to your phone, these are people who say, “That’s really important to them.” There’s a lot of things that hearing aids can do that DM systems can’t do. We both know that. I think every audiologist who has any experience with DM knows that. I actually have a couple of people who use hearing aids for their APD and they also use a remote mic attached to them. Either an NG mic or a Roger and they love that. It gives them a lot of opportunity and frees them for what they might want to do. It also is costly. There’s not any doubt about that. I think that we as a profession often jump to cost first and not jump to function and what the person is asking for. I know that cost is a huge issue for a lot of people. I’m not naïve, but I also think that sometimes, we put the cost first.

One of my best clinical supervisors ever at Michigan State University 30 some years ago, Roxanne Bonta. Shout out to Roxanne. Often told me that her grandma told her, you don’t climb into other people’s pocketbooks because you don’t know what they value. I have a teenager that I worked with who perceived herself as not very intelligent and was really struggling, and was a really phenomenal softball player in high school. The coaches would make fun of her because she couldn’t hear when she was outside and couldn’t play on the – they would say that she was dumb and they would call her all these things to her face, which I found offensive. Her mom [inaudible 00:42:40]. We tested her, she had an auditory processing issue, which should have been obvious from the time she was about five years of age from what her mom’s description was. We put hearing aids on her and this girl kind of went into it kicking and screaming, didn’t really want them, but wanted to do what appease her mom. 

Right before her 16th birthday she came in and she said, this has changed my life and I wanted you to know that. For my 16th birthday, I had a chance to get a car, but I want high-end hearing aid technology. That’s the choice that I’m making and that’s what I’m going to get for my birthday this year, which I think we all were like, “What?” She’s also a kid that when she was a freshman in college, she dropped in to visit me. She had like a sweater wrapped around her. I thought of it as kind of weird because I had never seen her sit like that before. She opened her sweater to flash me with a T-shirt that had an honorary, a college honorary and she said, three years of hearing aids has changed my life. I can hear what’s going on now. I could never discriminate between things. She said, I’m successful in college only because I can hear. It’s stories like those and I know people are like, “Those are anecdotal.”

Well, there’s plenty of research that’s not anecdotal. There’s a great article, it happens to be sitting on my desk. I jokingly told you, I was just finishing a presentation. By Doug Beck and Jeff Danhauer that was in the Journal of Otolaryngology and ENT Research in 2019. It’s a really well-done article that talks about hearing aids and auditory disorders that are not audiogram related. Francis Cook had a great study with kids – it was a small study, but a really great study with kids with APD 15 years ago. This isn’t something that people haven’t been talking about or haven’t been doing, but I think it’s getting a little bit more common or at least people are starting to think about this a little bit more.

[00:44:40] DS: Yeah. It’s really opened my eyes to this option. I’ve never been wanting to say, “Well, I got nothing for you. Best of luck.” But I think when I show someone like an FM system as an option, some people have been very drawn to it, but others are just like, “Well, that’s not for me.” It takes a lot of advocacy for themselves to be able to ask someone to wear a microphone and carry it around with them and keep it charged. I do think that – I see the flexibility 100%. It makes total sense. It just seems so intimidating to think to fit a hearing aid on a normal audiogram. But this, I mean, the research and the anecdotes, when you put it all together, it just makes so much sense.

Actually, to that point of those two worlds working together, your patients that you mentioned that wear hearing aids for their – will stick with the HD for tonight, right, with their hearing deficit. They use some kind of remote microphone technology. I’m just curious, because when we think of like how we have traditionally approached these patients, hearing aids are kind of a drastic new entry into that world. I’m curious how it just kind of fits into the bigger picture. Do you still maintain all of the other typical strategies that you would use? Are you finding that this is kind of like a pretty great panacea, like it’s just like wow a lot of problems are solved here? Or do you find that it’s just kind of one component for most people?

[00:45:57] GW: That’s a really great question. It really depends on the individual. From most of my traumatic brain injury patients, this works well but it’s not the full picture. I’m heartened to hear about – I really want to listen to the podcast with the speech pathologist who does TBI because finding a great TBI therapist for this population is tough. I sat in a clinical grand realm that was put on by part of our hospital, by SLPs who work with TBI patients. The conclusion that they came to and Dakota, I had my head in my hands and I actually was having a hard time not screaming at the computer while this was going on, was that – if these patients would just listen harder, they would do well. I’m like, “What the hell does that mean they’re going to listen harder? How do you tell somebody to listen harder?”

[00:46:48] DS: Oh my God!

[00:46:49] GW: For a lot of these folks, they’ve been dismissed from speech therapy because they’ve met their short-term goals. But the long-term aspect of this, the word finding, when they get stressed, the hearing aids help with that. They help with auditory fatigue. They help with executive functioning but they aren’t the be-all and the and-all. I have had patients where it was the be-all and and-all and they didn’t want anything else. I have had patients who want a lot of accommodations at work and ask for those. I have patients who are really compliant with doing oral rehab, like I mentioned. I actually have some adult patients who do auditory verbal therapy, because they feel like they’ve never really been trained if they can’t discriminate sounds. I have a phenomenal auditory verbal therapist that I work with who does a lot of work remotely. She does a lot of virtual stuff.

It’s easy for an adult to say, “Hey! I might want to do a few sessions of this” and they find it really useful. Again. I think the hearing aids for some people are just like for people with hearing loss with abnormal audiograms. It’s the be-all and the and-all and they’re done. Then for others, they really need some additional supports and we keep getting better and better at the supports. I mentioned Amptify, I think that’s a really cool program. It’s fun for patients. I just did a – I did a remote care consult with a patient on Tuesday. She was telling me about her experience with Amptify, which was really great. Amptify by the way isn’t paying me to talk about this. I just happen to really like it. We use LACE with a lot of these patients and that’s really effective. I have patients that are so auditory processing impaired that I will jump back to something like Angel Dound, which is really designed for cochlear implant users.

I’ve been really fortunate to work with very peripherally with some people with cochlear implants. I came to Ohio State from Indiana University school of medicine, where I had a lot of implant exposure in those days, but that was a long time ago. But what I find with a lot of my implant patients is, some of them are just as good at, if not better at discriminating sound that some of these patients with HD. I think that’s another thing, how do we look at functional communication. The World Health organization says that’s what we’re supposed to be doing, but we get hot on that audiogram, that piece of paper, which – if people haven’t looked at my very favorite thing in the world and I use it in almost every presentation I give Erber’s hierarchy. 

Norm Erber is an audiologist out of Australia and created this hierarchy of listening skills. It starts with detection at the point of the triangle. Detection is only a small part of what we do, there’s discrimination, and comprehension and identification. Those things are critical auditory skills. It goes back to what you might choose in a test battery. I base my test battery on looking at Erber’s hierarchy. When I’m doing that, it gives me insight into the patient who says, “I can hear everything. I could hear a pin drop in another room. I can’t make out what people are saying if there’s any background noise” or “My processing –” I just am writing a report right now, sitting next to my computer where the person said, “My processing is so slow. I can’t keep up.” That creates auditory fatigue and in adults, it creates embarrassment. We know that people don’t – you said about asking someone to wear a mic takes a lot. Asking someone to repeat themselves also takes a lot.

I think that the big picture is, we could be part of a really important team that we get to lead and we get to have great interdisciplinary and great interprofessional relationships for these folks and they are incredibly, incredibly grateful.

[00:50:42] DS: Wow! It’s such a helpful way to think of this approach and how all of the different – I feel like it’s such a – and into my work with a student, especially a fourth year. I try to demonstrate this to the best of my ability, but like, audiology, whether it’s in the education or I don’t know why, but it’s taught to be so segmented, that you’re either going to do this or you’re going to do that. You might mix in a little bit of this, but you’re definitely not – you know what I mean? It has to be very specialized, either you’re going to work with cochlear implants or not. 

I tried to do a lot of different things, because that’s – one of the fun things about audiology is there’s so many different aspects to it. I love that, yes, I primarily see cochlear implant patients, and I can’t tell you how some of my oral rehabilitation exercises with them can bleed over into my hearing aid patients and then into my newborns that are diagnosed. Like it at all just can come together full-circle.

Speaking of little apps and things that we love, again, neither of us are paid to promote any of these things, we just like them. Have you been using Hearoes, H-E-A-R-O-E-S?

[00:51:43] GW: I know Hearoes. I haven’t been using it, but I actually have it on my phone. Is that one that you think is a great one?

[00:51:50] DS: I’ve loved it. I’ve loved it. We definitely connected this way, how you said like I’m bored and I’ll just kind of play some of these like auditory training games. This is a great one for it, like it’s one of my favorite game set ups for one of these apps.

[00:52:03] GW: Excellent.

[00:52:04] DS: Big, big thing though. I think it was developed in Australia. When you first you first open it up to play, it set to an Australian accent. You can change it to an American accent, but I had a cochlear implant patient. She was a woman in her 50s who I had recommended – someone had recommended this app to me; I had played around in it and had changed the accent but forgot to tell her to do that. She comes in a week later and she says, “It’s fun. I like it, but I swear it just sounds off.” I was like, “Well, you’re new to your cochlear implant, things are going to sound a little off.” Then she opened it up for me and I was like, “Oh my goodness! I cannot believe I forgot to tell you to change the accent.” So yeah, that is a disclaimer on that one.

But yeah, I do love how you’ve connected all of those things. That’s a great way to think of it. We’re sort of coming up to the end of our time here and I know you’ve shared a few stories of patients who are really successful patients, who have had a little bit more difficulty. Is there any other specific stories that you feel like you want to share that are helpful for clinicians who are maybe still on the fence about this, or any kind of specific instances that come to mind that can really drive home some of the things we’ve talked?

[00:53:10] GW: I’ll tell you about my patient who did change my career in a lot of ways. It shows how necessary we are and it also shows how important speech and noise testing is. If nothing else comes out of this, please do speech and noise testing. I have a patient that was referred to me by a dear friend in the area where she lived. She was in the Boston Marathon bombing and I’m allowed to talk about her. I have all kind of HIPAA clearances on her, because she wants people to know about her. She was in the Boston Marathon bombing. She is an amazing patient, an amazing woman, young woman. She describes herself as very competitive and she was all annoyed because she came across the finish line after her friends and was wanted to have a faster time. She came across the finish line the first bomb went off and she fell to the ground. She looked up at the [inaudible 00:54:03] and she had friends who had lost limbs. It’s a horrendous story.

The second bomb went off as she was trying to get to them. They think a policeman jumped on her to try and protect her, but either way, she had a traumatic brain injury. She went back to work, everybody had time off that was in this, from April to June. She owned an Angel investing business, which is a business that matches people who need funding for their research ideas with people who are willing to fund. She loved this job and she’s so social and went back to work. Unfortunately, her business partner pulled her aside and she said, “Something’s wrong with you. You don’t listen anymore. You can’t hear. You sort of lost your hearing when you hit your head.” It made her start to think and she thought, “Oh! My business partner is just being kind of cranky.”

She went to an audiologist and described what had happened and described that – yeah, she’d been talking to her husband, and she tried to go out with friends and she can’t hear with noise anymore. She’s fatigued at work and it’s really hard for her. The audiologist told her she had a normal audiogram and she had PTSD, which by the way, guys, this isn’t in our wheelhouse. You can speculate about that, but we don’t diagnose that. She ended up in her community, which is a very well-known city with great health care. At seven audiologists within a year, how many of whom do you think did a speech and noise test, which was her main complaint?

[00:55:26] DS: My hope, 100% but –

[00:55:29] GW: A big fat zero.

[00:55:31] DS: Oh my goodness!

[00:55:32] GW: She went to an HLA, meaning one night because she was at her wit’s end and met my friend there who he was the presenter. He called me at like 10 minutes to midnight and he was like, “Whitelaw, this patient –” this was like in November. He’s like, “This patient is coming to you. You got to find a time in your schedule to bring her in. She’s flying in and I want her to talk to you and I told her all about you and you’re seeing her.” I was like, “Okay. Thanks. I appreciate the patient referral, but okay.” She happened to call in the next couple of days and she was very blunt at me. She said, “If I waste my time and fly to Columbus, Ohio to see you and you don’t do anything more than anybody else did for me, I’m going to be really angry and feel like I wasted a lot of money.” I thought, “Well, that’s [inaudible 00:56:15].”

She got here and we talked. I put her in the booth and she said, “I’ve had this before.” I said, “Yes, I know. I have some audiograms sitting in front of me.” A physician told her it was all on her head and that she needed to see a psychiatrist. She was treated so poorly. We start to do speech and noise testing and she can’t do it and she starts to cry. She said, “This is what’s wrong with me.” We talked about what the options were and we talked about hearing aids. I didn’t want to fit her here, because I didn’t want her to have to fight back and forth and this is in the days before remote care.

I found a [inaudible 00:56:48] of ours who worked in the city where she was, and she was willing to fit her and we medical clearance from a physician I had worked with and he was at the Cleveland Clinic and he was now in her city. I found a speech pathologist that I had done presenting with many years ago at an ASHA Convention on APD and she happened to be in her city too. Dakota, it was so incredibly life-changing and so incredibly heartening to see this woman go from someone who – she sold her business because she didn’t think she could do it anymore, but she could function in her life and her husband would tell us things like, “Oh my gosh! I’d given up on communicating with her, because if you turned your back on her, she couldn’t hear you or when she would get fatigued, she would just be so miserable and not want to communicate and our life is back to where it was before.” 

I didn’t even talk about electrophysiology tonight, and I’m not a big electrophysiologist, but there’s ways that we can verify some of these things, certainly electrophysiologically. But I think this woman was given a short shrift because we know that explosions and all that cause issues with traumatic brain injury. But there’s so much we can do. She’s always a guiding light to me. We still keep in touch and she’s very happy in her life, and I’m very happy that I got to meet her, and play a somewhat small role in her recovery and really see somebody who had been through such horrific stuff really come out well on the other end. For me, that’s what it’s all about.

[00:58:18] DS: That is a beautiful, beautiful story. Not only because she got to have such a positive outcome, but I love how it all came together with multiple professionals across multiple disciplines. That’s what it took to get her what she needed, unfortunately, but it’s a great reminder that not only do we have to be practicing at the top of our scope, but we need to be connected with people who do the same all over the country, because we don’t know when that need will arise. It’s going to arise at some point.

[00:58:45] GW: Totally.

[00:58:46] DS: Yeah. That’s a really, really great story. Thank you so much for sharing that. I’m so glad to hear it worked out for her.

[00:58:51] GW: Me too.

[00:58:52] DS: Okay. Well, we are just about at the end of our time. This has been awesome. I’ll be honest, this is our first-time kind of speaking together and you are way more hilarious than I expected. I love your sense of humor, so funny.

[00:59:05] GW: Thanks. I’ll tell you a little secret, I do improv and stand up comedy as my –

[00:59:10] DS: Get out of here.

[00:59:11] GW: No, really I do. It’s really great fun and it’s a great outlet. But I hate when patients, like if I say that to a patient, they’re like, “Well, say something funny.” But I’m like, “Well, I have been for like the past hour, whatever.” I guess, you don’t get my sense of humor.

[00:59:28] DS: Oh my goodness!

[00:59:29] GW: I always love when your roles can collide and I think that entertainment is one of the best ways to teach. I always want to believe that.

[00:59:36] DS: Yeah. Well, you’re crashing that game for sure.

[00:59:39] GW: Thank you.

[00:59:40] DS: I’m just so, so appreciative that you took the time to join us here to talk about this. I really think a lot of people are going to have a kind of a radical shift in their thought process here. and I really appreciate you doing this.

[00:59:51] GW: I hope they do and I’d be happy to support anybody or to debate anybody, however people want to approach this. I’m happy to approach it in any way that they find helpful.

[01:00:01] DS: Yes. If people did want to contact you, if they want to learn more or if they wanted to maybe hear your standup routine, what is the best way to get in touch with you?

[01:00:10] GW: You can email me whitelaw.1@osu.edu. 

[01:00:26] DS: Perfect. We’ll be on the lookout for emails from those listeners and thank you so much for joining me. I’d love to if there’s any topics in the future that you want talk about, you are just too knowledgeable and too funny not to have back on again for future episodes. Keep me in mind when new research comes up for you.

[01:00:41] DS: That’s very kind of you. Thank you. I appreciate that.

[END OF INTERVIEW]

[01:00:47] 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 Speech Therapy PD. 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. That’s speechtherapypd.com/ear.

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