A Veteran Audiologist On Tinnitus And The Human Side Of Care

The best hearing technology in the world still fails when we ignore the person wearing it. Host, Dr. Dave Fabry, kicks off a Legacy Series conversation with Robert Sweetow, former chief of audiology at UCSF, to look back on how hearing care evolved from screwdrivers and body aids to digital, apps, and AI hearing aids, and to ask a sharper question: did the profession grow more human along the way, or more device-driven?

Dr. Sweetow shares his origin story, training at Northwestern under Ray Carhart, and the real-world moments that pushed him beyond “matching target” into tinnitus management and aural rehabilitation. We get honest about why tinnitus is so emotionally loaded, why cognitive behavioral therapy for tinnitus became a turning point, and why many “miracle” sound solutions never delivered a cure. We also talk about what still frustrates clinicians and patients alike: uneven adoption of speech-in-noise testing and real ear measures, counseling that sounds scripted, and the lack of consistent follow-up that could prevent many problems before they snowball.

From bimodal stimulation to brain-wave driven algorithms, we explore what might be next and what should never be outsourced. AI can streamline fitting and tracking, but it cannot replace empathy, clinical judgment, and the skill of engaging patients so they actually practice, participate, and improve at home. If you care about patient-centered audiology, tinnitus counseling, and better long-term hearing aid outcomes, this conversation will leave you with practical ideas and a clearer view of what “fitting the brain” really means.

If this resonates, subscribe, share the episode with someone who cares about better hearing, and leave a review so more listeners can find the show.

Transcript

Legacy Series Kickoff And Purpose

Dr. Dave Fabry 0:05

Welcome to a very special episode of Soundbites. I'm going to call this the Legacy Series. And the brother that I never had, Robert Suito, is joining us today to talk a little bit about his career and uh the impact that he made and also some his vision a little bit uh for the past and the the present and into the future a little bit. And so uh first of all, you don't need to adjust your set, YouTube viewers. Uh yeah I don't want this to be two old guys yelling at a cloud saying, well, back in my day, um but uh we're gonna try to go a little deeper and and really um get into uh Robert's background a little bit and philosophy and and sort of we've both seen audiology change a great deal. Uh before we begin, though, if you uh have been enjoying Soundbites, please like this episode, uh share it with your friends, share it with your enemies for that matter. But um uh we always uh can bring more people to the podcast and to raise awareness for the importance of hearing and to hear better, live better. So, Robert, thank you for joining us today.

SPEAKER_00 1:08

Thank you, thank you. It's an honor to be here with you.

Dr. Dave Fabry 1:11

I see you dressed up for the occasion.

SPEAKER_00 1:13

Well, you know, I've I'm supposed to be here on vacation right now, and I was roped into you know doing this, and and you and of course I'm having to pay you, which made no sense to me. But uh, you know, I'm still honored to be here. I know you've done on these sound bites in the past, you've interviewed some uh very well-known people, Paul Simon, Alice Cooper, uh Huey Lewis. And I just out of curiosity, I'm just wondering on that scale, where do I rank in terms of fame and fortune?

Dr. Dave Fabry 1:44

Let's just say you're not even on the scale. See, yeah, you're you're you're you're off the charts on that. But uh well, we we have known each other uh a a long time, not since the beginning of your career. Uh and I do like when we have the majority of our audience are hearing care professionals, and and Robert really needs no introduction. He was the chief of audiology at UCSF for many years. He is now retired. You've really focused on areas, obviously, amplification was one of your primary areas, but your real passion was in um working with patients who had tinnitus um with oral rehabilitation, um, and really beyond the widget. And so, you know, I always felt like you know, we were involved in a lot of groups together, some of which we'll get uh to discuss a little bit, but but you really focused on that

From Iowa To Northwestern Mentorship

Dr. Dave Fabry 2:34

patient side of this uh beyond the widget. But um, let's go back to your origin story, though. I love hearing people's origin story to the profession. Many people may or may not know that you uh were a student of Ray Carhartt. Truly uh one of the pillars, if not the the center pool uh of audiology foundationally after World War II, when audiology was first established as a discipline, and you went to Northwestern. Um but but talk about what drew you into audiology, because really audiology was it's a young profession, but it was even younger back in the previous millennium when you started.

SPEAKER_00 3:10

Yes. Well, you know, I remember I I went to undergraduate school at the University of Iowa. Gohawks. And yes, Gohawk eyes. And um I remember I actually I remember starting in pre-dentistry, and I decided dentistry is not for me. Um I you know, I took a course in speech pathology and audiology at Iowa, which was at the time one of the meccas in speech path anyway. And I did well in it. It was the only course that I did well in other than physical education. And so, you know, I got into it, and I was very fortunate to get into Northwestern, which was really at the time the mecca of audiology with um uh Ray Carhartt, Tom Tillman, Wayne Olson. Um just it was uh Doug Knofzinger, Earl Harford. It was a tremendous group. So um, and Carhartt was just the most amazing mentor ever. After I got my PhD, I went out to work and I got a job in San Francisco, a place called the San Francisco Hearing and Speech Center, and you know, was there for almost 20 years and then got the call to go to UCSF, you know, and then when I went to the Hearing and Speech Center, I really focused on Tinnedis, and no almost none of the other audiologists were looking at it. And Tinnitus had such an emotional base. But but in once I got to UCSF is when I started also focusing a lot on oral rehab, largely because of I think limitations in my own work with patients when I would fit a patient with what I thought were great hearing aids, I thought I programmed them right, I thought I counseled them correctly, but they weren't completely happy with it. And so clearly I was missing something. Yeah. And so, you know, that's kind of how I got into that uh area as well. And again, all the whole emotional concept of when you see patients that you think you've done the right thing with and they're not happy, it's not a lot of people.

Dr. Dave Fabry 5:13

Have you really done your job? Yeah, have you really put the goal on what you should do, matching target or fitting the right technology? Yeah. And let's let's face it, let's call it like it is. When you first started fitting hearing aids at UCSF and at the speech and hearing, you were using a screwdriver to program them, not a computer.

SPEAKER_00 5:31

Not only a screwdriver, but ear trumpets and you know those thrones that the kings used to sit in that had the trumpets, you know, stuff like that.

Dr. Dave Fabry 5:38

You dragged all of those in. I remember seeing a couple in your office.

SPEAKER_00 5:41

Yeah, no, I seriously I remember when I started, there were still a lot of body aids being used and things like that. And of course, the BTEs were massive. Yeah.

Dr. Dave Fabry 5:51

So uh But we talk about in the media today. I I get frustrated every time I see media coverage of hearing aids because they're still using body aids or some of those monster uh behind-the-ear type devices to depict hearing loss, which certainly doesn't help us with stigma. But yeah, but you know, you know, we've seen and you've seen the technological advance that went from uh trim pots and and so did I, uh, to digitally programmable, then digital, and now AI and devices. But um, do you think that audiology has become too dependent on the widget and not focused enough on that emotional side where where you've always felt at home?

SPEAKER_00 6:27

Yeah, I I I I definitely do. And I think that, you know, I I think part of it is the patient's emotion, but it's also part of the audiologist's emotion that you know, as a professional, you don't want to fail. Yeah. And so part of my recognition of failure with certain tinnitus patients, you know, I was doing different kinds of counseling. And at the time when I started in this, I remember I received a lot of criticism for this when I suggested cognitive behavioral intervention approach to dealing with tinnitus because the the big thing then was tinnitus mascars, which really didn't work. But I remember when I first brought this up, some of the leaders with tinnitus mascers said to me, you know, you're gonna kill federal research that we're trying to get on using sound therapy for tinnitus because you're saying you're making it sound like it's a psychological problem. And I would say it's not a it's not a psychological problem, but there's such a huge psychological and emotional component to it that if you don't address it, you're you know, it's like not addressing the elephant in the room. Right. So, you know, so yeah, so cognitive and I'm uh you know, I'm very happy about that. And I think that now, even um I think the Academy of Odolaryngology recognizes that the one proven approach to tinnitus, and there's been so many technological advances by modal stimulation, different kinds of things.

Dr. Dave Fabry 8:02

And stimuli, the array of stimuli that people, even an individual, can sometimes benefit from green

Tinnitus Care Beyond Sound Therapy

Dr. Dave Fabry 8:08

noise, pink noise, white noise, you know, all of the different colors of the rainbow of noises. And you've been you've always reminded me that that temporal, that ability to adjust the temporal fluctuation, slow, medium, and fast, that's critical to our tinnitus management system that works in combination with CBT, is that we allow people to vary the rate or turn off modulation if they want to.

SPEAKER_00 8:30

And you know, and I'm a little surprised, actually, that the field has not advanced even further in tinnitus. Mm-hmm. Why not? Well, for example, uh like for example, if you would have said to me three years ago about bimodal stimulation when that was first being talked about, I would have said that I think that's the best idea yet. Years before that, I remember working with the idea of again, and this goes back to the emotional component and relaxation for tinnitus patients, but trying to alter the alpha waves using binaural beats.

Dr. Dave Fabry 9:05

Yes, I remember.

SPEAKER_00 9:06

And so I thought, well, maybe that's the way it's going. But I'm guess I'm I'm di a little disappointed in that we still don't have we're nowhere near a cure for tinnitus at this point. And I'm happy to see a lot of different approaches coming out there. But again, I I mean, I think back on my career, there were so many technological or manufacturers that came out with different products that it made it sound like this is it. Right. This is what's gonna do it.

Dr. Dave Fabry 9:36

And it's really we stand on the shoulders of giants. I mean, you think about Jack Vernon, yeah, you think about uh, you know, there's so many Jim Henry. I'm I'm gonna miss people. I mean, Tyler, you, yeah, uh, Grant Surgefield is doing interesting work now, and people are incorporating AR and VR into sort of the diagnosis of tinnitus and mapping it out space. That still doesn't necessarily lead to treatment options, but there so I think that's a fair thing. We and people are looking for a tinnitus solution that is similar to Ozempic, you know, just take a pill is the great American way, and we haven't yet seen a medical surgical intervention. You know, there are supplements that people take and swear that it helps with tinnitus, and maybe we're on the precipice of some advances there, but it always feels like it's just a little bit out of reach.

SPEAKER_00 10:22

Trevor Burrus, Jr. Yeah. The other thing was like even with in the amplification field, I must admit that I thought that middle-ear, not middle-ear implants, but different kinds of implants, aside from cochlear implants, were going to become much more prevalent in today's world.

Dr. Dave Fabry 10:39

And I have worked closely more on the device side of things, but um but I thought middle-ear implantables, especially as we saw the rapid advance with digital technology and something that was non-invasive, the reversibility. I would be with you if you could try a fully implantable device that was reversible, but I always had some trepidation about recommending it to the patients that I was working with because I knew you couldn't return it just easily after a 30 or 60 or 90-day trial period.

SPEAKER_00 11:08

And the other one is I thought the disposable hearing aids, when they first came out, other than the fact that they were all, you know, like a one f one size fits all, which doesn't work. But I thought that that was going to be really big. That disposable, you know, just like with contact lenses. I thought that would be the way people would want to go. And, you know, and it turns out that's hasn't been the case either.

Dr. Dave Fabry 11:28

You know, not yet. I mean, we maybe we'll see that come around again, but I thought, you know, there were people, not only uh some of the devices that came up, but I think those that focused on a single form factor of different frequency responses was challenging because as we say around here, the ear is the boss. Uh Mr. Bill Austin and Ray Woodworth always constantly remind me of that, that the ear is going to dictate how uh comfortable you know that sound is delivered to the patients here and whether it's popping out of their ear or anything else. And we haven't really seen that yet. I always another name out from the past, uh Don Morgan, um uh after he left UCLA was working on something that had an articulating joint that gave more functionality. But we had you're right, we haven't seen anything like disposable the way that it took over for contact lenses.

SPEAKER_00 12:10

Yeah, and yeah, and and I th I thought it it would have. And so uh there's so those were some of the areas that I think I really kind of miscalculated. Well, in fact, if I remember correctly, in the year 2000, in the year 2000, yes, uh we you also we wrote for an article about our predictions for the next millennium. Yes, and I remember I had some things in there, and I still would have liked to have seen, and I think Starkey should be able to do this, would be to you know be able to translate your dog's bark. So you got your hearing aids on, your dog starts to bark, it should say to you, oh, my dog's hungry, or oh, my dog's angry, or something like my dog's nervous. So, you know, those were some of the things that I whimsically thought would would come about in in hearing aids.

Dr. Dave Fabry 13:00

Some of the things that we did say translation, which we do now, and uh and incorporate that right within the app for multiple languages. We don't do canine yet, yet. Yeah, not yet. Um but uh but indeed, you know, uh some of the things that you predicted. But I I will say that we'll we'll go back and we'll go to the mattresses and look to see who had a better accuracy on their prediction for 25 years in the future later, and we'll put it on social media. Who who wore it best, who made the best predictions.

SPEAKER_00 13:27

Well, you were a lot older than me at the time, and so yeah, and now I'm older than you, but it's all it's all been reversed. So I think your your predictions might have panned out better.

Dr. Dave Fabry 13:36

So I guess I'd summarize this portion but from the work, the integral work that you've uh contributed, both in terms of tinnitus and in oral rehab, uh, in the words of Picasso, I think, who said that great artists steal, and you stole from different disciplines, whether it was psychology uh or speech language pathology, to say audiologists should own this. And I I do want to use the remaining time. We only have uh we've as usual, I knew this would go quickly. But um the other thing I'd like to talk about is maybe a few reflections, uh, maybe a quick hit format on things that have happened or things that you might see differently from your vantage point. Um uh now uh 40, five, fifty years uh uh uh of your career. How long have you been? And uh uh when did you get your PhD?

SPEAKER_00 14:22

I got my PhD in 1977 from Northwestern. Yes, yeah, yeah. 1977. So yeah. And I've and I've been retired since basically since 2016. Some might argue longer.

Dr. Dave Fabry 14:34

But uh but yeah. Okay, so what's an opinion you held strongly 20 years ago that you've completely changed your mind about now? Now you mentioned a couple things in terms of things that you may have predicted or thought, like like you said, bimodal or tinnitus treatment or implantable. But is there anything else that you can think of where you had a strong opinion about something and you were you are, in my mind, the best presenter that I've ever had the privilege of listening to within our field. And and so you need to get out there a little more often, sir. But in your opinion, what's it what's an opinion or uh something you held strongly 20 years ago that now you look at and reflect on differently?

SPEAKER_00 15:12

You know, I it's a tough question for me to answer because I'm not really up to date on you know what some of the audiologists are doing. I guess I'm a little disappointed. I thought diagnostic audiology would progress further than it has. I thought there would be way more testing. I I think now more you know most audiologists are doing speech and noise as opposed to when I started when it was, you know, you just did the NU6 lists and that was that. And I but I don't know if that's really been universally accepted. Same with real ear measures, is that universal? You know, I think that like in the field of audiology, I I recently was asked to do a presentation at one of the universities about, you know, how is audiology different now than when I started? When I first of all, like I've never done a vestibular test in my life. Even at Northwestern, balance was not.

Dr. Dave Fabry 16:02

You didn't do calorics?

SPEAKER_00 16:04

I didn't because I was afraid the patient would vomit on me. So, you know, I wanted to stay out of the way. You know, so we didn't do vestibular thing. Uh a lot of what I've gotten into in the past several years that I think is really fun for audiologists, is uh forensics, yeah, which has been really uh, you know, an eye-opener for me with some of the cases you could get into. So, and I still feel that um a lot of the counseling, you know, one of the things that would bug me with

Tech Predictions AI And Clinical Reality

SPEAKER_00 16:32

students, and I still once in a while, when I do watch students, I still see them, you know, asking questions off of a piece of paper.

Dr. Dave Fabry 16:40

Yeah.

SPEAKER_00 16:40

And, you know, you get a question, we'll say, uh the patient will say, Yeah, I don't really want to try these hearing aids because I have an aunt who tried them and hate and threw them away right away. And then the next question the student says is, Um, did you know anybody in your family that's ever worn hearing aids?

Dr. Dave Fabry 16:57

And so You gotta adapt.

SPEAKER_00 16:58

Yeah, and I remember counseling, I remember doing a counseling video showing, you know, audiologists taking the patient from the lobby back to the test room where the audiologist was walking in front of the patient and talking with, you know, with the patient behind them. So the patient couldn't hear, couldn't see, you know, all of that. And so I I don't know how much counseling has progressed. You know, just like with oral rehab, there's a lot of talk about it, but I I don't know, and and you know, you would know more than me being more in contact with audiologists now, how much that's really changed. But I hope it's changed a lot.

Dr. Dave Fabry 17:36

You know, time is of the essence for clinical chair time, as you know all too well. You had you knew what clinical revenue per hour you needed for the booths that you had at UCSF. That hasn't changed. The numbers have changed, the balance have changed. It's a topic beyond the scope of this discussion with third-party pay. For many people, it's a pain point because they're they're pressed to figure out how they can generate enough revenue to be profitable. And so oral rehab often still falls off. And so I think you have to meet the patient where they are. We've, as I said, tried to work out ways to do ecological momentary assessment to get patients' uh impressions of how they're doing in the real world, in their real world environment. And we try to tap into streamlining that process to take the burden off of chair time in the clinic, which is expensive. Uh and and so really using those tools, and you talked about you're using whether you again you're humble in terms of using AI tools. Yeah. But but at the same time, as AI becomes even more proficient at assisting in the fitting process and the outcome process, what will the audiologist's role become in five to ten years is a big question. I don't expect you to have an answer.

SPEAKER_00 18:46

But yeah, and I and I don't have a great answer, but again, you know, I think that there's always going to be a place in terms of like forensics, in terms of uh counseling, you know, AI is not going to counsel. Right now, you look things up in AI and there's mistakes being made. And, you know, and I think that um, you know, one of the biggest problems I think that audiologist certainly was for me, and it's a human, it's a human nature thing. I think that there's a lack of follow-up. And again, maybe AI will help generate some of that by saving time and things like that. But I think that there's a tendency for audiologists to be a little afraid to pick up the phone and call the patient three days later. How are you doing with the hearing aids? How are you doing with this tinnitus approach? I do. With oral rehab now, because of AI, we are able to track is the patient doing the therapy and things like that. But I think that, you know, at least for me, it was always a concern. I would hate, I I I was reluctant to call my tinnitus patient six months later and say, I just wanted to check up to see how you're doing, and all of a sudden have my patient say, I completely forgot about my tinnitus until you just mentioned it, and now my ears are ringing like crazy. So, you know, I think that that may be something that will evolve, and that's where AI can be of use. Certainly, you know, the like you say, the fitting formulas and all that are going to really shorten the amount of time that the audiologist could be you doing something else. And that something else has to be the emotional connection and you know, and the follow-up and all that.

Dr. Dave Fabry 20:26

Yeah, and I and I would say that, you know, recognizing one area, uh you mentioned vestibular, that you never really were involved in vestibular. I mean, my mom died of the consequences of a fall where she broke her hip. She didn't die from the fall, but three years later we were together in the Virgin Islands with the I Have Fitting Group, which was one of my favorite professional experiences. When my my mom, you know, um was going downhill and uh and she had started that downhill fall after the consequences of a fall. We recognize that in many cases, many audiologists think about hearing and little balance as within their scope. But but so we've been slowly working on a path where we had fall detection and then balance risk assessment, balanced training exercises, all that can be done in the comfort of the patient's own home if if they have the the room to do these balanced training exercises that were developed by the CDC. But we've seen the uptick in that because now we're enabling the baby boomer patient, who I think is less stigmatized than their parents, um, and will engage in things that connect to overall health and wellness, but we had to lower the clinical barrier to help assist the professional in uh working with their patient to understand both hearing and balance. And I would say the oral rehabilitation is that other link that we still need. And and and that's why I really wanted to talk about this in depth with you today.

SPEAKER_00 21:45

And also you mentioned somebody who says it's all about the ears. To me, it's the ear is the boss, yeah. Yeah. And to me, it the ear is not the boss, the ear is the secretary, the eye, the brain's the boss. You know, I know that there's, you know, new research that just recently. Just came out about using brain waves now with you know letting the hearing aids sense the brain waves and uh have an algorithm that adjusts based on what the brain waves are saying and things like that.

Dr. Dave Fabry 22:11

So you know I I think there that's yeah I guess I would say the ears are sensors. So hearing you know, we we we are not just fitting ears, yeah. We're fitting the brain. Yeah. And I think that's for me the thing that I've learned over the last decade or more is consciously thinking about not matching target, not thinking one ear and another, fitting binaurally, of course, but really the impact of what we do is at the brain level and what we're trying to work on with DNN and AI is is to really try to mimic the way that the brain processes. And that that's a weighty problem. Um

Legacy Patient Engagement And Closing

Dr. Dave Fabry 22:43

when here here's coming down to the last question. So when future generations look back at your career, if they do, um, what do you hope they say that you changed? What's your legacy?

SPEAKER_00 22:57

This podcast, I would say. No, I want a serious answer. Yeah. I would have to say well, again, I would have to say the focus on patient participation much more so than relying on the therapist or the audiologist. And I would say that recognizing that I really try to portray that the professional has to recognize their own limitations and recognize the importance of engaging the patient. And you know, and again, I would you know hope that the cognitive behavioral approach on tinnitus still will remain as one of the main until a cure comes about, that that's still going to be the big thing. And I would hope also that, you know, in terms of oral rehab, that you know, people will think of me as you know being one of the first people to really say this could be done at home. It it but you have got to engage the patient and somehow motivate them and the audiologist to push this and motivate the patient to participate and engage in it.

Dr. Dave Fabry 24:04

We have both been very fortunate to find a profession, and I guess the parting words, and I'll speak for both of us uh Ikigai or finding your passion, that we found something that we could sustain us in the same profession for 40 to 50 years. We've traveled the world on our ears. That's how we became friends, and and for me it's been one of the delights of my career to have uh the opportunity to meet you on the and we were both with the IHAF group. We're on the triple A and American Academy of Audiology board at the same time. Um, and um it's been quite a ride. Uh I'm not quite ready for it to be done yet. But and I don't think you are either.

SPEAKER_00 24:40

But uh well, you know, I mean it's amazing considering that you're old enough to be my father that you're not ready. But uh no, I I know, and I know you know what you're what you're still continuing to do in the people that you're interviewing, the people that you're working with, you know, it raises the awareness of audiology. And so it's you know, and I think what you know it's what Starkey's doing with you know and other manufacturers as well, just is bringing uh bringing a whole new generation of uh science to to the field of audiology, which is great.

Dr. Dave Fabry 25:13

Would you choose audiology as a profession again today, knowing what you know?

SPEAKER_00 25:17

Yeah, it's a tough I I'm not a hundred percent sure. I mean, you know, if clearly, you know, at at five foot six, if I clearly am not gonna make it in the NBA, you're not that I'm not, huh? Then I might still choose audiology. But um, you know, again, because there are a lot of new branches of audiology to go into, I would say yes. And I again I I really hope that diagnostics are really gonna vastly improve in audiology. And I hope that AI doesn't cut too much into audiology. So I would I would choose it again in that you really get to help people, and from an altruistic perspective, it makes yourself feel good about knowing that you're helping other people.

Dr. Dave Fabry 26:03

Yeah, yeah, absolutely. And for the students and new grads out there, without hesitation, I would choose audiology again. I'm just as excited to get up and go to work every day today as I was 40 years ago. And uh now we'll just give it one more good uh boomer, old man yelling at a cloud. Get off my lawn. Uh and with that, um, Robert, I will thank you for being with us today on Soundbites. And our listeners and viewers, thank you for tuning in. As I said before, like, circulate, uh, and learn. And uh we look forward to seeing and hearing from you again really soon.