OTE 34                Transcript
EPISODE 34


[INTRODUCTION]


[00:00:00] ANNOUNCER: Do you enjoy listening to On the Ear, but wish you could earn ASHA CEUs for it? Start today! SpeechTherapyPD.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On the Ear, you can receive $20 off in annual subscription when you use code EAR21. Just head to SpeechTherapyPD.com to sign up and use code EAR21, E-A-R-2-1 for $20 off your annual subscription.


[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.


[INTERVIEW]


[00:01:36] DS: While many audiologists specialize in different types of care, such as tinnitus, vestibular, or cochlear implants, few emphasize the distinct connection between our field and that of musicians. Musicians are a population that rely on hearing for so many aspects of their career. Their relationship with their audiologist should be rock solid. Many audiologists do not have a foundation in music, and so working with this population can be really intimidating.


Today's guest is going to help show us how embracing that challenge can be so rewarding, and how embracing maybe an alternative point of view can also be so rewarding. Dr. Heather Malyuk, owner of Soundcheck Audiology, is a musician and audiologist who hails from Northeast Ohio, but is known internationally as an expert clinician and public speaker in the fields of music audiology, tele-audiology, and alternative amplification.


Heather grew up in a musical family and, since the age of two, has been singing, playing piano, violin and fiddle and guitar. In her early teens, she began teaching music, touring, and recording. She received an undergraduate degree in music history and literature from the University of Akron, and continued on to earn her doctor of audiology degree from Kent State University. From 2013 to 2017, she was the Clinical Director at Sensaphonics Hearing Conservation in Chicago, and she is actively involved with the American Academy of Audiology, and recently co-authored The Clinical Consensus Document for Audiological Services for Music Industry Personnel.


She is on the leadership advisory team for the National Hearing Conservation Association, and is a co-chair of the College of Music Society's Committee on Musician’s Health. Since 2020, she has served as Head of Audiology for Tuned, a groundbreaking virtual audiology clinic. In addition to her extensive clinical and educational work, she developed and manages the first-ever hearing wellness video curriculum for the music industry. She's a sought-after consultant and she's a research team member at the University of Akron, where she's studying pharmaceutical intervention for noise-induced hearing loss.


[DISCLOSURE]


[00:03:20] DS: Just a couple of financial disclosures, I am the host of On the Ear and receive compensation from SpeechTherapyPD.com. Dr. Malyuk receives compensation from SpeechTherapyPD.com for her contribution in today's presentation.


[INTERVIEW]


[00:03:33] DS: We are so, so fortunate to have Heather joining us. You can tell she is highly in demand for her expertise, but I know that our listeners are going to be so excited to learn more about all of your knowledge. Heather, thank you so much for joining me.


[00:03:44] HM: Oh, thanks for having me.


[00:03:45] DS: I mean, your CV is outrageous, okay. It's so long. That's not even getting into all of – I'm sure you've done a lot of traveling. Just person-to-person here, clinician-to-clinician, I'm also a musician, not nearly as accomplished, but I play guitar and I was in an all-male acapella group in college. This is actually the first time I'm sharing this on the podcast, so that's a yikes.


I have always loved incorporating some of that music knowledge into my practice. I can't say, even in the slightest, that I'm in any way a music audiologist, because I just don't have any training in that. I'm curious, what led you – other than obviously, your extensive musical background – what led you into a clinical focus that was in this specialized part of audiology?


[00:04:30] HM: That's a great question. Thank you for that question. I love getting this question, in case there are students listening. I was in graduate school to become an ethnomusicologist. That had been my chosen life path for most of my life. I play old time Appalachian music. I was very interested in ethnic music from my family, Slavic music, and I decided to go that path. Well, what happened was, about my first week in graduate school for that degree, I found out about audiology and had what my dad called a come to Jesus moment.


I saw the word and I was like, “What is this?” It was an ad online, actually, for the local program here, the Northeast Ohio Audiology Consortium. I went to the library. People always seem to laugh when I say that, but this was back in the day when you went to the library. I looked up books on hearing and audiology, and I was blown away. I was so blown away and captivated immediately, that as a musician, the one sense that I relied on, I really knew nothing about and it had never come up. Even with getting a degree in music, it had never come up.


[00:05:39] DS: So interesting.


[00:05:40] HM: Yeah, it is really interesting. We can get more into that in a bit in terms of why doesn't it come up for musicians and where can audiologists change a little bit. To make a long story short, I ended up applying for the Northeast Ohio Audiology Consortium, NOAC, and wrote a very basic entrance essay that said, “I'm a musician, and I love my hearing, and I'll work really hard and yada, yada.” They ended up taking me.


Then, through school, I always had a huge interest in hearing conservation as it related to musicians. Every time I did a project, or had to write a paper, I tried to keep it music focused. I read every article I could, even to the point during my final year in classes and clinic here in Ohio, I did a large grant rounds presentation on an opera singer, who had sudden sensory neural hearing loss and really bothersome tinnitus.


Then I had the pleasure of meeting Michael Santucci, who is one of the fathers of music, audiology. At the time, he really was not taking students. He had taken one fourth year student before me years, years prior. I met him at a conference. He was willing to sit down with me. I pleaded my case, and he said, “Okay, I'll take you on.” Then, at the end of my year there as an extern, he said, “You've got to stay and direct my clinic.” That was my journey into audiology. After about five years or so, I guess almost six years at Sensaphonics, I decided to come home to Ohio, because I have eight nieces and nephews. I was missing everything. That's my whole story in a nutshell.


[00:07:16] DS: Wow. That's really, really cool. I had no idea. I do want to get into that though then, because I have a very close friend who was in that college acapella group with me now, who is a professor at, oh, my gosh, I can't believe I'm blanking this, at a great music university in Nashville, Belmont. He's a vocal instructor. He is an amazing artist. His name is Mark Thress. I need to make sure he hears this. I remember, early on in his career when he was working with students, well, especially when we were in undergrad together, I was taking these communication disorders classes. He was so interested in everything I was learning. He started taking the same classes as me, because he was so interested in this.


It does sound like, there's no inherent anatomy of hearing or hearing conservation component in music education. Before you mentioned, maybe talking about that a little more, is that something you could expand on?


[00:08:07] HM: Yeah. You know what? There is. There is education available, but there is a divide on how it's presented. A number of years ago, the National Association of Schools of Music and the Performing Arts Medicine Association put out some guidelines on how to teach hearing health. What's so funny is I was – I think, I was in my first year of grad school or something. My sister, who is just an amazing classical pianist, was a professor at a university at the time. I remember her saying to me, “I don't know how to teach this.”


They got a handout saying, you've got to teach ear anatomy. Here's what a decibel is, and all this stuff. There's a real divide there. That's my way of saying yes, it is out there. It is out there. The curriculum I created covers the NASM guidelines. NASM is one of the accrediting bodies for schools of music. Technically, they're supposed to follow that, but it’s not a requirement. What we often see and this is what had happened to me when I was in music school is audiologists who will see music students, and we'll take ear impressions on them and fit them with hearing protection, and that's all they do. This is so true in all of music world. I do think it's shifting.


For example, I think of the music audiologists who started in the 80s. I mentioned Mike Santucci. I think of Lisa Tannenbaum. I'm sure a lot of people know her name. To me, she's one of the most famous audiologists I know. I mean, she was working with all the rock stars in the 80s and 90s, trying to teach them hearing health before it was even a thing. Things have certainly changed since then, but we still find overwhelmingly that audiologists do not – they often don't even test hearing on musicians. They'll take ear impressions. They'll either make a sale, or they'll just have the artist pay for the impressions. Then, it's a go with God thing.


Now, these days, there are some Au.D. programs that have music management classes. I don't know if I'm getting the name of the class exactly right. I know there's an audiologist, Matt Bell, who I had met years ago. He's in Portland, Oregon, I think. I believe, he was teaching a management of musicians class. I do think it's getting better and it's expanding. In terms of reaching music students and things, often, they're just presented with earplugs. Then, that's the end.


[00:10:28] DS: That's a really great insight. I am fortunate that here at the University of South Carolina, the music department here reached out to our department and said, “Hey, would someone be willing to do at least just a guest lecture on hearing health and safety?” That's something I get to do each spring. This spring, for the first time, I connected with their department. I guess, the music students take a wellness class in this is one semester, in their undergraduate career. It's on a lot of things related to the life of a musician, and then hearing health is one of those aspects.


At the end of this month, we'll actually be going there and doing hearing screenings for as many of the students that sign up. They can have that experience. We can possibly catch any hearing loss that might be there. If not, they just feel a little bit more acquainted with the process of a hearing evaluation, even if it's just a screening. Then, our students get the experience of doing hearing screenings.


I'm really excited to see more about that and explore their ideas about hearing a little bit in those screenings. I'm curious, if you know a clinician who's going to be maybe speaking at a high school where there's a lot of music students, or in a situation I'm in, where they're going to be seeing a lot of music students, what do you feel like is a critical word of advice for – I guess, this is a double-layered thing, right? Word of advice for audiologists to tell students who are in a music-related field.


[00:11:42] HM: I think that part of hearing conservation in general, and of course, music audiology expands into amplification, which we didn't even get into yet. When you're speaking with young musicians, one of the key components of hearing loss prevention or hearing conservation is education. It is a bit of cheerleading. I hate to say it that way. So often, audiologists focus on being doctors of hearing loss instead of doctors of hearing. That's the message that comes across.


When I speak with younger musicians, I sit down with them. Actually, I had a family in my office recently. That was speaking to high schoolers. It was three kids and two parents, all musicians. It was their first time getting custom earplugs. We spent the afternoon together. We spent three hours together. I gave a lecture and I said, “You know what? You've got these amazing instruments. The only person who can help you take care of your instrument is an audiologist. What if you never took your trumpet, or your violin, or your drum set, if you knew someone could look at it and tell you if damage was starting? If injury was starting to that, wouldn't you want to know?”


I take my bow to get re-haired. Or I have a guy I work with here in Northern Canton for my fiddle, to do a setup and things like that. When you put it into terms like that, about it being an instrument, and caring for it in such a way and learning the parts, just like when you're learning your instrument, you learn all the pieces and parts of your instrument. I try to frame everything like that, as if they are a music student, but the ear is the new instrument they're learning.


[00:13:16] DS: That's a great idea. That's a really great way to put it. I think that's really impactful. Thank you so much for sharing that. I think, I'm definitely going to be stealing that, if that's okay with you.


[00:13:25] HM: Please do. That's great.


[00:13:26] DS: That's awesome. Okay, so then let's get in – I know, you were just hinting at amplification. Amplification, evaluations, hearing protection. Do you only work with musicians? Or do you see the general population as well?


[00:13:38] HM: I see some of the general population. Up until COVID, it was full-time music industry for me.


[00:13:43] DS: Oh, I see. I see.


[00:13:45] HM: When they stopped working, I stopped working.


[00:13:47] DS: Oh, I see. Oh, wow.


[00:13:49] HM: That was it. The whole music industry shut down. I'm part of the music industry, or I was. I have started expanding into more things now that I didn't get the chance to do before, because I was too busy. In a way, it was a blessing. It was a real heartache for a year. Yeah. The tours are coming back, and I have some orchestras lined up for this year. Pre-COVID, it was full-time musicians. Now, it's 50 percent music industry. Then maybe 25 percent research and 25 percent Tuned.


[00:14:22] DS: Oh, got it. Cool.


[00:14:23] HM: The company I work with. Yeah.


[00:14:24] DS: Cool. I just bought my first concert ticket in two years. I'm so excited.


[00:14:29] HM: Who are you going to see?


[00:14:30] DS: Phoebe Bridgers.


[00:14:32] HM: I don't know who that is.


[00:14:33] DS: Oh, gosh. I'm a die-hard fan. She's alternative singer/songwriter. Very excited about that. Yes, I can feel the world, especially the world of live music getting back to where it was little by little.


I'm curious then, I guess, maybe if you don't have a frame of reference for it, maybe if you think back to your AUD training, how your work with musicians, whether it's an evaluation, fitting amplification, and this is a really broad question, so take it in any direction you want. How does your work with musicians differ from a more general population? If you think an older adult with presbycusis, or a child with a congenital hearing loss. What makes working with a musician differ? Or how do you approach it differently?


[00:15:14] HM: Well, I'll just tell you what I do. When I think of who I would call a music audiologist in the US, I can think of maybe six, or seven people. I know, we probably do things a little differently. I'm just saying that for the people who are listening, this isn't how we all do it. Now, that being said, if you are listening, and you're interested in starting to see musicians, the American Academy of Audiology guidelines for working with music industry personnel is essentially a guidebook for that. Many of us got together and wrote that as a reference.


When someone comes to see me, I always book at least an hour. I probably spend more an hour and a half with them, if it's your first visit. The first, gosh, 30 to 40 minutes is all education. I actually have a three-ring binder with pictures and graphs and all kinds of things. Everything in my clinic can fit into a suitcase, because I used to do everything backstage at venues. I used to pull up to the venue, go backstage, and there'd be five guys from the band and 10 from the crew sitting around and we do education. Then, I do a full hearing test on everyone. A 125 Hertz to 16,000.


I recently have added the words in noise test. What's very interesting about that is I'm not seeing what I would expect. Their words and noise scores are lower than I would expect, even with their extended high frequencies being very, very good. The bulk of the appointment is education. Of course, if they're getting something like earplugs, or in-ear monitors, with in-ear monitors, I often do a lot of demoing. I'm in my clinic right now. Next to me, I have for any of you who knows sound, I use a Fender Passport System, which is not a very good system. I have a little setup with speakers. It's leftover from my days of being a street performer at Disney World, to be honest.


[00:17:07] DS: Wait, hold on. We might have to dive into that a little bit more. You can’t just gloss that over. We’ll come back.


[00:17:14] HM: I'm using my same equipment. I'm using the same equipment that I used as a performer. It's now set up in my office. With ambient in-ears, I'll do demos and things. I really like a hands-on approach. I do the same thing with hearing aids. I'm really big on getting paid for my time and expertise. For example, I'm totally unbundled. I spend a lot of time with people. I give them a lot of value, and they pay me well for it. I do the same thing with hearing aids.


My office, when I see someone from the general population or musicians, it's very interesting to see their differing reactions to amplification. I'm on a street that has restaurants and shops and things. Often, we'll go on a walk, if it's not raining or snowing, and we'll listen to things that way. I'm going off track of your question, but it's –


[00:17:55] DS: No, no. This is exactly my question. Yeah.


[00:17:57] HM: A ton of education, a lot of hearing testing. Then of course, educating about the hearing testing. I'm a huge fan of questionnaires. If I get someone with tinnitus, I'll probably do – I like the TFI a lot. I usually do that to see, to gauge where they're at. I like to do the HHIA, if I'm doing amplification, so that I can do it at one month, three months, six months, that kind of thing and check improvement. I like to pack a lot into an appointment, and I don't like to rush it. People pay me for 15 minutes blocks of time.


Whatever it ends up being, that's what it is. I haven't had any complaints so far. Sometimes I overdo it. I'm so big on education that sometimes I drag on and on, especially when I get a full band in here. I had a full band in my office a couple months ago. They were on tour. They stopped in. We could have spent all day together. That's what I love about the music industry. If you really start teaching them things, they just start – the questions start pouring out, and the conversations start. I really, really love getting a whole band together, and having it be an experience with everybody. I just had a band call me the other day. They all want to be seen together. We make it a big hearing event. It's not like someone going to the doctor. It's a journey we're all taking together.


[00:19:15] DS: I love it. I love it. That sounds like such a really cool and unique experience and such a fun way to – I mean, counseling and education is such a big part of what we do. I guess, it's not uncommon for me to see a husband and wife. Actually, currently on my caseload have a mother and daughter and the daughter is a teenager and the mom’s in her mid-30s. They have the exact same cookie bite hearing loss.


That counseling is always really fun, because we can speak more to their personal life together and their experience together. A band, a group of five people who've probably been together for a long time, who were in extremely dynamic listening situations, who maybe all have a completely different perspective on what's safe. You know what I mean? They probably all are just on completely different pages sometimes That's got to be a really fun challenge in terms of counseling and educating.


[00:20:04] HM: It is. It's often really fun. Pre-COVID, of course, this would all happen either on the tour bus, or backstage. That's starting to come back now. One additional thing I would do on site is take sound level measurements, get an idea of how they're playing, watch what their heads and necks and jaws are doing, and take that into account when doing ear impressions. I like to be there during soundcheck and see all of that. I don't always go to the shows, because I'm not a night person anymore. I don't know what happened to me.


When I first started, when I first graduated, I was out at shows all the time. I was just talking to a student the other day about how one time I had to wait till 3 in the morning to test somebody’s hearing after the show. I can't imagine doing that now. I like to go for soundcheck. I'll hang out a little bit, and then I'm done.


[00:20:50] DS: That’s so cool. That's so cool. You gave me a little bit of a sense of the evaluation process. I would say, it's probably pretty rare for most audiologists to do 125 to 16,000. It's just a whole different set of equipment. One thing I find challenging about it, I mean, I rarely do that maybe in an occasional ototoxicity monitoring case. I wouldn't say I regularly incorporate anything past 8K beyond that. I just find, for someone who isn't going to be fit with any amplification, let's say their hearing loss is just 12,000 hertz and above. Well, I'm probably not going to recommend amplification.


I feel like, I'm not as equipped to answer their questions, as to other than protecting your hearing. What do I do about this loss of these ultra-highs? I just feel like it would – it complicates my counseling process. I'm curious, what you think about that, and how you approach that. Let's say, they have normal across the board, and then it's steeply sloping in the highs. It just gives you an opportunity to, I guess, to be a bit more, I guess, aggressive is the right word. Aggressive about hearing conservation like, look, here's the warning sign, here's the red flag.


[00:21:54] HM: Sometimes it's from noise. There's certainly literature to show that extended high frequencies can show injury. A lot of musicians have asymmetric loss. If they're staying at the same part of the stage for years and years, they might have the drummer to their left, or a wedge monitor to their right, or what have you. I'll give you an example. I think, this was about a month ago. A guy came in, he was – I'm trying to remember how old he was. Late 30s. I think, mid to late 30s. He had been to see an audiologist and he went in because he knew something was off.


He said, he was missing the harmonic structure, the overtone structure of music. He went in and got a hearing test. Gorgeous thresholds, 250 to 8K. He emailed me his test ahead of time and he's like, “I think I'm going crazy. The audiologist told me my hearing’s perfect. I'm not sure what's going on here.” He came in, there was an asymmetry in the extended highs. I said to him, “I don't know when this started, but you're not crazy.” That was enough for him. Again, using the term instrument for ears, to own his instrument and want to care for it, he got scared. He went and had an evaluation done, and was told that he's totally fine. That was very disturbing to him.


Now, the other thing that could be done, of course, is otoacoustic emissions. I don't have that equipment, partly because when you look at hearing conservation, when you look at regulated conservation, well, what are we looking at? We're looking at 3, 4, and 6K. That would be something that could be added. If someone's listening and they're thinking, “Hmm, my audiometer doesn't do extended highs. How could I maybe find injury sooner?” Well, you could assess outer hair cell function.


Although, I just read a paper recently that said, 40 percent to 50 percent of outer hair cells could be injured. Oh, no. That was for audiogram. Excuse me. See, this is what we talked about before we started recording. Does it matter if I skip up on my words? I said, no. Don't edit that. Just leave it. 40 percent to 50 percent of outer hair cells can be injured or missing and not show up on the audiogram. That's what I was going for. That's what I'm saying. If you have something like, OEE equipment, you could pull that out and show the person, “Hey, you were actually right about your hearing. Here's what we can do to mitigate this injury that's happening.”


[00:24:08] DS: That's great. That's really awesome. I appreciate you making it a little bit more approachable for someone who's new in this realm, or considering this thing. Because it can certainly be overwhelming, especially – I mean, speaking from having very close friends who are all musicians, they're almost always very smart and know what they want, or at least sometimes. I feel like, if you aren't a musician and somebody starts asking you about overtones, or things like that, your response is going to be, “What?”


Maybe their expectation is, “Well, you're an audiologist. You should know everything about sound,” but we never learned about overtones and harmonics and things. Well, I guess some harmonics, but you know what I mean there. I guess, that can be a little bit intimidating, I guess, is probably the right word.


[00:24:49] HM: Yeah. Yeah. When you look at the literature on extended highs and things, they can be variable. The other thing is, I do want to point out, people might be listening to this thinking, “Well, how is she doing all this testing on site?” I use an audiometer called a KUDUwave. If I don't have good sound level measurements in the room, that's why I say, sometimes it's backstage, or on the bus. I have been in a shower stall in a bathroom, backstage with people. I've been in the back of my car with people. If you're going to be going out and working with artists, you have to be aware of whether or not you're getting accurate results.


[00:25:24] DS: Sure. That's another level of the equipment and the outside expertise that it takes. I'm assuming, you have to be pretty confident with a sound level meter. Tell me a little bit about your impression process. I'm assuming, I mean, we all are trained to do impressions in a similar way, I guess. I'm curious, if there's an approach to it that maybe an audiologist you've worked with, who hasn't worked with musicians, they do impressions one way. You're like, “Oh, no. When it comes to musicians, you've got to change it up in some way.”


[00:25:52] HM: Yes, I do. I think, we could break it down into just a couple main points. With any hearing conservation, not just with musicians, but any hearing conservation, it is better to use a high-viscosity silicone, so that when you're taking the impression, it's going into the canal and it's actually distending it a bit, so that you're getting a tighter fit. Of course, we wouldn't want that with an acrylic hearing aid. Because that could be painful. That would be the first little difference.


Now, a lot of audiologists who do take ear impressions for in-ear monitors, they might be thinking, “Well, okay. The difference is that you use a bite block with musicians.” A lot of in-ear monitor companies call for use of a bite block. I'm actually not sure where that recommendation came from, because I see many fit issues doing things that way. There have been a couple of studies done looking at holding the jaw open halfway, and some ear canals, it's either – I think, it's about 50 percent, the ear canal diameter gets a little bit larger. That may have been where that started. The funny part is, okay, you can get a fit with their jaw open, but then, what happens when they move their jaw and the seal breaks?


To me, it is what it is. Of course, sometimes you're at the mercy of the manufacturer of what your person is ordering. I tend to not work with those types of manufacturers. I only fit silicone in-ears. When you have the impression material ready, I usually have them just start with that slightly open mouth in case there's a chance they might have a little bit bigger space there. Then when the material is setting up, I have them do any movements that they would do when they're wearing the earplugs, or in-ears.


I make sure I get well past the second bend. Your best isolation is going to be past the second bend of the ear canal. For a good steady fit, good isolation, and then of course, a full helix if you're doing something like an in-ear. I have a great example of why an audiologist should know what the musician plays. If a musician calls the clinic, ask them what they play. If they use something with a mouthpiece, have them play it. If they play flute, or a saxophone, or clarinet, or whatever, have them play that instrument. It's even better if they're not shy and they'll do exactly what they do.


I had a guitar player who I was working with. Very famous guy. I had never seen him perform before. I had fit him with in-ear monitors a couple of times. He consistently had fit issues. I felt terrible, because I was a young audiologist at the time and I thought, “What am I doing wrong?” His monitor engineer invited me to come to the show. They were opening for Bob Dylan. I thought, “Okay, cool. I'll come.” It was a festival. It'd be fun. I saw him play for the first time.


As soon as he picked up the guitar, his head started going back and forth, shoulder to shoulder. Looking to his left, looking to his right. He had never done that with me. Every time he did that, he would push his left ear back in. It was coming out. I had actually seen him for an appointment before that show and I texted him after and I said, “I'm so sorry, I have to see you again. We need to get new ear impressions. Just trust me.” Did the whole thing again, but had him do that head movement, and he did not have a fit issue after that. I was working for Sensaphonics at the time. I know, we made a note in his file that the ear impressions need to be taken that way. 


There are little things like that, the head bangers, that it really moves your ear canals around. Probably not true for everybody. I don't think everybody's that dynamic. I think, he was an outlier. That was the first time I really thought, wow, I'm not just following a protocol here. This really matters.


[00:29:24] DS: That's great. I think, I'm seeing a really common thread in everything you're saying, which is when you're working with this population, the importance of things being ecologically valid, whether you're walking down the street with the hearing aids on, or they're taking the impression with the way they move and the way – all of those aspects of it. I mean, I think that's such a fascinating thing.


Honestly, I'm not too tuned into the literature on ecological validity in audiology. I personally have a set of speakers when I'm doing a hearing aid fitting, and when there's particular things. It's hard to perfectly simulate a noisy restaurant. At least, I have this one video on YouTube that's a busy coffee shop, and I play it every single time. If we're working with a remote microphone, if we're working with – I try to add some layer of that.


I’m hoping that the future of audiology is a lot more of that because, every single clinician, there's no way you haven't heard someone say, “It sounded great in here, but then I went out there and it was totally different.” I mean, whether it's one of my cochlear implant patients, or hearing aid patient, I hear that thing pretty often. The way you combat that is bringing the outside in, if you can't go out there.


I'm wondering if you can speak to that a little bit. I know, we wanted to talk a bit about alternative audiology or this moniker of approaching things differently. Is that an aspect of it? Or how do you see incorporating ecological validity in your clinical practice, beyond taking a walk with the hearing aids, or that great example of doing impressions that way?


[00:30:51] HM: It's funny, you bring up the hearing aid thing. I feel like, maybe I shouldn't ask this, because we're being recorded. When you're fitting a patient, before they come in, do you ever put the hearing aids on and program them and walk around outside yourself with them on?


[00:31:04] DS: I have never done that.


[00:31:06] HM: Most music audiologists I know, do this.


[00:31:10] DS: Interesting.


[00:31:11] HM: I do it, too. Of course, I have receivers I put on and stuff, making sure they're working. I don't put my KUDUs on somebody else. Usually, when I do a programming, I like to get an idea of what the pair of hearing aids I'm going to be putting on them actually sounds like, and program them a little bit from there. I was just curious if you do that, too, since you were mentioning doing things in the clinic.


[00:31:35] DS: No. I've never tried that before. I have tried, most of the time when we have a demo pair from the manufacturer, I'll try them out for a day or two, especially for things like streaming, I just want to hear what the streaming audio quality is like, but never fit to the patient's loss and tried it out. I think, that's a really interesting idea.


[00:31:52] HM: Try it some time. I have been surprised several times, when looking at the loss, even when it meets target, following best practices at how you can improve the sound quality.


[00:32:06] DS: So interesting.


[00:32:07] HM: You can tell the difference with the patients. Again, I didn't invent that. I learned it from a couple other music audiologists. Now granted, most of my hearing aid patients are in the music industry. They're listening for different things. Anyway, back to your question. I think a really simple way to put things is consistently asking ourselves, why do we do what we do? One of my favorite things to ask students recently has been the simple question, why do we test hearing?


It usually takes them a few minutes to give me a good reason, in terms of why do we do the test the way we do it. When was the test invented? When was it last improved upon? Getting back to the basics of what we're doing and not just following the recipe. Everyone likes to say audiologists like recipes. We like cookbooks. Sometimes we get lost in that, and we don't really consider why we're doing what we're doing.


[00:33:00] DS: That's great. That's a great reminder. I'm wondering if that's a good transition to talking about what alternative audiology is. I did, before we switch gears into that, which I guess it isn’t a major gear switch. I did just want to speak – have you speak a little bit to hearing conservation in general, and what a general audiologist, who doesn't even necessarily work with musicians, how maybe you've heard them council hearing conservation before, and how maybe you think, as a profession even, we need to shift either the way we talk about it or the way we train students? What work needs to be done when it comes to audiologists and hearing conservation?


[00:33:38] HM: Boy, that's a loaded question.


[00:33:40] DS: I know. I'm sorry. I know it's a lot. It's a lot. We can cut it up. We can cut it into different smaller questions.


[00:33:47] HM: The thing is, what's so interesting about the field of audiology is that it's full of wonderful people who really care. That's something I really love about our field. All of us got into this – Well, most of us got into this field, because we love people, and we want to help them. Then, we get these shackles put on us by the model of what makes our worlds turn, which is income and sales, and things like that. I think part of it, I'm hesitating on what I say, because I really don't want to offend anybody. That's not what I mean by this. What I mean by this is, we're often limited by how our field has been structured. So many people can make more money off of a sale of hearing aids, than they can off of seeing someone for a quick hearing test and recommendations on how to protect your hearing.


I think, so often, it comes down to that. When you run your own practice, like what I do, of course, you can do whatever you want. My friends who work in practices where they have a manager above them, or maybe it's an ENT running the practice, or things like that, they're often not really allowed to spend time with those patients, the time that they would need. I spoke with a friend of mine recently who saw someone come in for a pair of just custom earplugs for recreational shooting. It was a 15-minute appointment. It was just come in, take the ear impressions and send them on their way. There was no time allowed for care.


I don't think that's a unique situation. I bet, there are people listening to this nodding their heads, where they're at the mercy of whatever the structure is. That's the first thing I just want to put out there. I do think people are limited. I also think that partially comes from bundling of pricing. Why can we make more on hearing aids? Well, it's a bundled model. There's an expectation there. I'm trying to get back to the main point of your question.


[00:35:34] DS: No, no, no, no, no. I think, this is all super relevant. I'm loving this.


[00:35:39] HM: In terms of non-OSHA regulated hearing conservation, that applies to everyone, which is 700 million ears in our country, roughly, which would be what? 63,000-some patients, or ears an audiologist. How are we not caring for all those ears? A lot of the limitations, of course, now telehealth is opening doors left and right. Hearing testing, education, recommending earplugs if they're needed, perhaps counseling someone on how they're listening throughout their day. I can get into this more when we talk about alternative stuff. We have a workforce now that's listening to headphones and earphones eight to 10 hours a day on calls with remote work.


If there's ever been a time for hearing conservation, it's now. It's now. We know the World Health Organization is saying that, by 2050, the rate of hearing loss is going to double. They have already said for several years now that 1.1 billion young people are at risk for hearing loss. I guess, where's our community? I think a lot of that comes down to people maybe not understanding the principles of hearing conservation outside of that regulation environment.


[00:36:53] DS: Just thinking of OSHA every time. Yeah.


[00:36:56] HM: Correct. OSHA 1910.95, the law, you can take that and modify it for each person who comes into your practice. I learned how to do that from Mike Santucci. Now, I've taken my own spin on it. One of the things I do with pro orchestras is I go on site, and I do all the testing with everybody for a week and it's modeled after OSHA, but it's not a regulated area. Any audiologist can look up that law and write out the main points of it and say, “Well, how would I do this with a 25-year-old who might come into my clinic and is wondering.” Okay, here's a perfect example. I see a lot of people marketing air pod sleeves, custom sleeves. Gosh, what a great appointment for hearing conservation.


That could be an hour appointment with education, a really great hearing test, talking to them about how to use them properly, etc., etc. Looking at other noise exposures they have in their lives. Again, if any audiologist is thinking, “Well, I don't really know how to go about this.” There's a really great organization called the National Hearing Conservation Association. Like all of us music audiologists are in there, and a lot of other people who work in hearing conservation. There are so many resources for you available.


Hearing conservation tends not to really have a lot of spotlight, or a place in some of the other larger organizations. For those who are really interested in it, NHCA is really the hub. It's the home base for that. If this is an area you want to expand into, I would say, join, and start talking to people. One of the great things about NHCA is that all of us are really, really accessible. We're always happy to talk to anybody. If you have a particular area that you're interested in, you can actually just speak to someone in that area and learn from them.


[00:38:47] DS: That sounds perfect. I think, that's a really helpful resource for everyone. I agree. I mean, I remember at some point in my doctoral program, having a good section. Honestly, it might have even been a class, but it was a short summer semester class on occupational audiology. A lot of the focus was on this could be a career path where it's more noise management factory settings. It wasn't just blending this concept into your daily practice. I do see a major need for that thing. I think, that's really great. It's a great perspective.


[00:39:20] HM: Yeah. I remember my noise class. I remember people in my cohort just thinking, or saying like, “Well, I don't think we're really going to use this.” It was viewed as an easy class. I remember being really, really excited about it. I knew I wanted to work in hearing conservation. I didn't know what realm exactly. I remember bringing it up to one of the older professors, who has since passed away. I remember being told that it was no place for a young woman.


[00:39:46] DS: Wow.


[00:39:47] HM: I think now, all of us need to get into hearing conservation. It's the place for all of us.


[00:39:52] DS: Sure. What a horrible comment. Gosh.


[00:39:56] HM: No. I know I thought it was really cute. She was really sweet. No, no. She had my best interests at heart. It was actually very endearing. I think, hearing conservation is often viewed as this tough, you go into factories, or you're in a van.


[00:40:09] DS: Oh, yeah. You're in the factory. You got to wear your hard hat.


[00:40:13] HM: Yeah. Yeah. I mean, hearing conservation is so much more than that.


[00:40:17] DS: Absolutely. Cool. Well, okay. Then, let's transition then into this idea of alternative audiology. When you first mentioned it to me, I did a little bit of Googling, and I was like, I can't really find anything too specific here. I'm trying to prepare a little bit. Can you break down what that concept is and how it came about?


[00:40:33] HM: Yeah. Honestly, it came about because somebody called me an alternative audiologist. I call any non-hearing aid device that amplifies, I call it alternative amplification. I often talk about fitting alternative amplification. Then, another audiologist said to me, “Well, it's really alternative audiology.” I think it's true. I hope in the future, it won't be alternative. It'll just be audiology. I think right now, it's viewed that way. It's not really an official term, but I know a lot of audiologists who are like me. They are all alternative audiologists.


It's not just music audiology. I do tinnitus management and, of course, tele-audiology, alternative amplification, even research I feel like is a little bit of alternative audiology. I guess, it's anything that isn't regularly practiced by the friendly neighborhood audiology clinic down the street in the traditional method.


[00:41:27] DS: Absolutely. What draws you into approaching things that way?


[00:41:31] HM: I don't know exactly, other than I think, number one, I've always been a bit of an entrepreneur. I think it's because of my background playing gigs and working as a musician. I like to do different things. I like to be in charge of my own schedule, for example. Sometimes, that lends itself to doing odd things. The other thing is, I always like to look at new tech. I like to see what's coming down the pipes and what the newest thing is, and what might be best for my patient.


One of the things that is intriguing to me is when a patient comes in and says, “I bought this device, or I saw something online. Can you help me work with it?” Of course. If it's helping, if we can measure benefit in some way. If not, then sorry. You might need something else. I think, alternative audiology, in a nutshell, is anything that's not in that traditional model. Now, that being said, I think there are other alternative areas that have existed forever that don't get the credit they deserve. I think of things like interoperative monitoring, even vestibular work. Gosh, I would never do vestibular. I think it's so cool that people do that. It's not for me. Even pediatrics or educational. There's all these sub specialties within audiology, but yet, the general population thinks audiologists fit hearing aids.


[00:42:50] DS: Yeah. That's what this series is that we've been doing with the podcast every couple episodes or so, calling it the full scope of audiology and just exploring. This is one of these episodes will be these different aspects. We've had an episode on interoperative neuro-monitoring, we've had an episode on vestibular. Just trying to explore some of these topics. Because I'm so fascinated by it. It's one of the things I love about audiology is all of the different ways you can practice it. I appreciate this idea of alternative audiology.


I'm curious, if there's – obviously, it's not a written down ideology. If there's a principle to approaching things this way that you feel maybe a student who – I think of a student or maybe an audiologist who's been at it a while and is just feeling disheartened by whether it's the repetition, or the feeling of being locked into practicing a certain way, what you would say to that person who sees the more cookie-cutter side of audiology?


[00:43:41] HM: I think with the students, it's a little easier, because they haven't locked into a certain career yet. I find that they're the most empowered to do things a little differently. Perfect example, I'm speaking with a doctoral school cohort. I don't know what year they are. I was speaking to them, and probably, would be second or third years, about other things to do in audiology, besides just going in to a hearing aid clinic, or how you incorporate different things. With someone who's been in the field for years, I've been letting people shadow me with tele-audiology, for example. Because I think, a lot of people who have been doing the same thing for a very long time just don't have the confidence. At least that's what I'm seeing.


They say, “Oh, this is really interesting. I'd love to do this. I just feel awkward.” It's just not their norm. The other thing is, maybe they're wondering about income. That's just so true for a lot of people right now. Afraid to leave the model they have, because they're not sure if the income level will be the same. I'm here to say, yes, it will be. You just have to get used to it. That's really what I'm saying, audiologists are so well trained and so smart. There's so much we learn, not just during our four years in doctoral school, but as we continue to practice, that I feel a lot of that knowledge and information gets left on the table.


I think, one of the beautiful things about this field of what we're calling alternative audiology is reaching into that knowledge base and using all the nuggets of audiologic wisdom to reach new people, rather than getting stuck in one area, saying, “Well, I learned about this. I can do this.” I think, what I've been seeing again, in the couple of years I've been working with Tuned and getting people into this area of audiology, they have this renewed sense of wanting to learn, which I think is really, really nice, where they're looking up articles. They're sending me articles they're reading. They're seeking out specific things to learn, even in new specialties.


Someone asked me recently about, gosh, what was it? Oh, I'm totally blanking. It was a field of audiology I really knew nothing about and I don't work in. I said, “Hey, go for it. If you want to do it, go for it.”


[00:45:50] DS: That's awesome. That's awesome. I think, that's one of the things this podcast is trying to inspire is that love of lifelong learning, that trying something new. I think, one of the things I'm really going to take from our conversation is really generalizing some of the knowledge that I might – if I see somebody who's in a factory setting, I might spend more time on that hearing conservation approach, but not really think about it as much for someone else. I think, you're really making it clear how good it is to generalize that wide knowledge base we have, that it doesn't have to be so segmented for certain kinds of patients. That's really, really helpful.


[00:46:26] HM: It was implantable devices.


[00:46:27] DS: Oh, okay.


[00:46:28] HM: That's what I was blanking on. It was programming BAHAs and CIs remotely. I ended up pointing them to another audiologist who could maybe help them, because that's – I really don't know anything about that. But that's what it was. I said, “Yeah, make a tele-audiology clinic. If you can do it, make it happen.”


[00:46:45] DS: Can we jump to tele-audiology, then? I mean, this is such an emerging thing and it's interesting. Where I'm at, we're a speech and hearing clinic. My speech colleagues are – I mean, they had a little bit of teletherapy options, pre-COVID. I mean, once the pandemic started, most of our students, most of our SLP faculty members, they were seeing a ton, and still to this day are seeing a ton of teletherapy clients, because the model works really well for SLPs.


I know from the conversations I've had with other audiologists, and sometimes even with myself, the hesitation about, okay, well, how's this going to work? If I have to physically manipulate a device. That's a big part. I see a lot of cochlear implant patients. It's a big part of what I do. How do I show them, this is how you remove the microphone cover? How do I show them that the cable is broken? I just worry about that. Then, I also think about how much of my job and how much of my time is just counseling and education and how that can easily be done, and might even be more effective when they're in their home and they can say, “Well, I sit over here and my wife sits here,” and I can say, “Well, look how far apart you are, and look how close you are to the refrigerator, or the TV.”


I can see both sides of it. I'm curious, what you say to someone who's a little bit more skeptical about the future of telehealth and audiology?


[00:47:59] HM: Well, it's interesting. I was looking up some – actually for the lecture I'm doing tomorrow, I wanted to give the students a context of tele-audiology. I realized, I didn't really know when it started. I don't know if you know this, but the concept of telemedicine was written about in The Lancet in 1879. Not kidding you. This was on an NIH article. I read this. That was the first article and telemedicine. The telephone had just been invented. Already, the medical community said, “Wow, this can really expand our care.” To me, that was fascinating.


Now, of course, many households didn't have a phone. It didn't take off, obviously. In the 1950s, people started using it a little bit. I thought that was interesting too, because when I think of tele-audiology, I think it's this new thing. The term tele-audiology was coined in the 1990s. I don't remember who coined it. I'm sorry, I'm blanking on the name. That came about in the 90s. What's really interesting just today, on one of the audiology Facebook groups, I saw someone make a post about tinnitus. I saw another audiologist comment and say, “I've been doing tinnitus therapy via telehealth since 1997.”


First, let me start by saying, let's give a nod to those audiologists, because that's really – talk about forward thinking. To me, that's phenomenal. We all think this is some new thing we're creating. It's not. There are pioneers in our field, who've been doing this for years. Now, COVID changed things. The rate of telehealth visits is 38 times higher now than it was in 2019. That's a statistic I saw recently. What I'm finding with telehealth is I'm seeing people who are in their 30s, 40s and 50s, mostly, who are work from home and who are experiencing severe listening fatigue and they don't know what's going on. They want to get a hearing screening.


Now, things like a cochlear implant fitting, or hearing aid fitting, it can be done, of course. I have done a hearing aid fitting remotely. It's different, but it's doable. I think, it depends on the clinician and patient and what you feel your patient can handle. I have one patient I'm thinking of. She has a smartphone, but she's 82. She's a nun. She's a choir director. She wouldn't be a good fit for telehealth.


[00:50:20] DS: Sure. There's some limitations, obviously. Yeah.


[00:50:24] HM: Yeah. She's someone who needs to come in and see me. Then, I have other people who are in their 60s. I'm thinking of a couple more hearing aid patients to make this more normal and not music audiology related, who are great over telehealth. We've done Bluetooth sessions, how to use your app, how to clean the hearing aids, so that it really lessens the time of the initial visit, and then we follow up via telehealth.


I really view it as a hybrid moving forward. There's some doom and gloom in the audiology culture right now. I really see it as really just expanding our practices. The idea of alternative amplification and telecare, bringing new patients in who you wouldn't have seen before. You might be thinking about your cochlear implant patients and how they would work via tele-audiology. On the other hand, you might start doing tele-audiology and realizing, that's not who you're seeing on there.


[00:51:16] DS: Oh, that's a good point. Yeah.


[00:51:19] HM: I saw a woman recently who's 30. She works in transcription. She works 10-hour days. She told me that by the end of the day, her ears are so tired that she doesn't want any sound on at all. I took a look at her setup. She's got a set up from the company she works for. I said, “Well, what's going on here?” She said, “Well, by the end of the day, my volume is at a 100.” I was like, “How long do you think your volume is at 100?” She's like, “At least five hours.”


[00:51:43] DS: Oh, gosh.


[00:51:45] HM: Because of the recordings she's getting, and the fact that her headphones aren't great, this and that. Anyway, I ended up doing a full hearing screening with her, which includes the SEDRA, and which is a great questionnaire for looking at capturing disease, like ear disease. I did a threshold screening with her online and I did the digits and noise test with her online. I like to do thresholds and digits and noises like a cross validation. I don't like to ever just do one online screening tool. I don't think it's enough.


In any case, she was well within normal limits. She really didn't have any complaints, except this listening fatigue. She thought, maybe something was really wrong with her. I ended up saying to her, “You know, I think you're a good candidate for SonicCloud. Download it to your laptop.” I had her check with IT to make sure it would work with her software she was using for transcription. Now, this is a non-music person. This is a normal person who wanted an appointment with an audiologist. She learned how to use SonicCloud to EQ what she's listening to, for speech clarity. She's able to keep her volume much, much lower. She's at less than 70 percent. All because of EQ.


I really think that's the new world we're walking into. Our current patients aren't going away, but we're going to be gaining millions of new types of patients. I really think that's where we need to be ready. That's really hearing conservation.


[00:53:10] DS: That's a great, great, great message, and a really great perspective. I also see a lot of the Facebook groups are just doom and gloom central. I feel like, the people I talk to on this podcast are just way more inspiring and optimistic. I tend to take on that perspective, because of the people I get to talk to. I really appreciate that perspective and seeing it – the current patients aren't going anywhere. It's a whole new group that we haven't even thought about that we're going to be exposed to and learning from and working with. That's awesome. That's a really great way to put it.


[00:53:38] HM: Yeah. I do think audiologist should look at the tele-audiology scene, sometimes with caution. A lot of the tele-audiology platforms right now are in relation to a device purchase. That has bothered me a little bit. That's one of the reasons why I was excited to be Head of Audiology for Tuned to help guide the process. It's me and the other two audiologists, who I work with are Dr. Kathleen Wallace and Dr. Laura Sinnott. We do a lot of things, looking at what's the best scenario for the audiologist and the patient? How can we keep this totally brand agnostic, no devices or anything need to be recommended to patients?


It's purely about putting the audiologic expertise out front. Because when you really think about it, that is what the patient needs first. Devices come later. I think, so often in our field, we’re device led. Whether it's earplugs or hearing aids, that seems to always be the first part of the discussion. Really, it should be hearing and audiologic care. That's number one.


[00:54:41] DS: That's awesome. That's really awesome. I'm excited to see what comes from your work with Tuned and how that shapes the future of tele-audiology, and I think that perspective is awesome. We are really coming close to the end of our time, and I would be remiss if I didn't ask you about your days busking at Disney World.


I wonder, if you want to close this. I didn't want this to be a real – raunchy is not the right word. I wasn't out looking for raunchy. You know what I'm talking about. I didn't want it to be a gossipy like, “Oh, tell us about all the stars that you've worked with.” I was curious, if you have a really – a story that you'll never forget. Not necessarily – they didn't have to be somebody super famous, but just an experience in this music audiology world, that you feel like, hey, if you're a student out there who's even considering this, listen to this story. This is going to be so crazy.


[00:55:28] HM: Oh, man. A million are going through my mind right now. I try not to tell my craziest stories ever. It's so funny. The other music audiologists I know, we often say, we’ll write them all down. Then, when we're all dead, they can be published.


[00:55:40] DS: Oh, my gosh.


[00:55:42] HM: I'm not as wild as I used to be. Actually here, I'll tell a story of from when I was a student, and I don't even have to mention a band. It was the moment I knew I had been accepted in the music audiology community. It was my first week with Mike Santucci as my preceptor. It was my first time going out to see a band with him. It’s a band that's country folk, but they've become quite famous. He says to me, “Okay, I don't want you to say a word. You just stand here. You observe me. Just be really cool. Don't ask anybody for an autograph, whatever.” The whole spiel that we give students before we go to see bands.


We walk into the venue, and the fiddle player from the band goes, “Heather? What are you doing here?” I will never forget the look on Mike's face when he goes – because he hadn't met them yet and he goes, “You know them?” I was like, “I used to play with them a little bit.” That's one of my favorite memories.


Of course, there are great memories from shows and working with people. Some of my favorites have really been, again, when the whole band is together. I remember this one band I was working with. They all had the gnarliest earwax, which typically, and I don't know why. I don't know why. It was just these guys. Typically, in the clinic, you get these patients who are like, “Oh, that's so gross.” These guys loved it. They did videos on it, all this stuff. That was a really fun memory.


Then of course, just to finish out my best memories, I occasionally take students. My best memories are watching students interact with famous artists. I had this one student, the first student I ever had, we were working with a really, really famous singer. My student, he was just really cool about it. Anyway, they ended up exchanging cellphone numbers, and they're still friends today. I'm just like, this is the coolest. I think, the hallmark of a good music audiologist is just loving on people, and meeting them where they're at. Especially when you're working with the big crews and artists, just viewing them as everyday people.


Of course, my heart has always been with the crews. Not that I don't care about the artists. They're cool, too. I love working with the guys who are building the stages, who are mixing the sound. They're the blue collar of the music industry. They're so often overlooked. They're my favorites. A lot of the good times that are going through my mind is with those guys.


[00:57:55] DS: That's awesome. Well, thank you for sharing that. I think that that's definitely going to be enough to inspire a lot of students out there and maybe clinicians who have always considered this. Now, I do want to give a very big disclosure here. Just because you take some of these tips, does not mean you're going to be taking impressions for Justin Bieber.


I would love if you're willing to share some of your information, if people have further questions, but those questions should not be things like, how do I get backstage passes? Because I don't think that's step one in working here. I think, you hit the nail on the head there at the end there. It's about loving the people that you're working with and being really passionate about hearing conservation and excellent audiologic care. If someone want to reach out to you with questions that are related to that aspect of things, how could they go about it?


[00:58:40] HM: They can email me. My email address is heather@soundcheckaudiology.com. If they have questions about tele-audiology, or Tuned, which the website is tunedcare.com, my email address for that is heather@tunedcare.com. I'm happy to help with either aspect. I will say too, I keep bringing up Mike Santucci. He taught me most of what I know in this field. He does have a course called Gold Circle, which he used to give in person. He's putting that on to videos, so people can always keep their eye on Sensaphonics for when that's released, if they really want to go through more in-depth training on how to work with musicians.


[00:59:18] DS: That's awesome. Thank you so much for plugging that, too. I didn't get a chance to mention it earlier, but I'm sorry, Soundcheck Audiology, being audiology for musicians is the best name ever.


[00:59:26] HM: Thank you very much.


[00:59:28] DS: That’s so awesome. That's awesome. Cool. Well, thank you so much, Heather, for joining me. This has been just one of my favorite conversations I've ever had on this podcast. Thank you so much again.


[00:59:36] HM: Thanks for having me.


[END OF INTERVIEW]


[00:59:39] 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. That’s SpeechTherapyPD.com/ear.


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