The Social Disability That Doctors Keep Ignoring

Most people think of hearing loss as an inconvenience. What they don't realize is that untreated hearing loss quietly rewires how the brain processes information, pushes people out of conversations they once loved, and as new research is showing dramatically increases the risk of ending up back in the emergency room.

In this episode, two geriatricians explore the hearing loss crisis hiding in plain sight: the patients who nod along in clinic visits without hearing half of what was said, the simple amplification tools that change everything, and the question no one seems to be asking often enough.

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FEATURED PHYSICIANS
 
Dr. Dan Osterweil
Co- Director, Geriatrics | UCLA Health
 
Dr. Joshua Chodosh 
Director, Division of Geriatrics and Palliative Care  |  NYU Langone Health

The information shared in this podcast is for educational purposes only and does not constitute medical advice. Please consult a qualified healthcare provider for guidance specific to your situation

Transcript

SPEAKER_01 0:00

So what is the big deal about hearing and aging or hearing at all from the population health perspective? It's it's a disability and it's a on this episode, Dr.

SPEAKER_00 0:09

Dan Osterwil sits down with Dr. Joshua Coda. They're talking about hearing loss and aging. And what's being done in the field to aid those slowly disappearing from conversations, they can no longer follow it.

SPEAKER_03 0:22

It's a functional disability and it's a social disability.

SPEAKER_01 0:25

She was a petite lady, very hard of hearing, and she was coming into the clinic and couldn't hear a word of what I was asking.

SPEAKER_03 0:33

Is he only 75% audibility of having some doctor and the doctor's office? It's hard enough to remember what that person just said to you. And the same point of picture, that's usually kind of a fundamental experience, right? It's a lot of emotion. What are they going to find? What are they going to tell me to do? Am I going to feel differently about myself? Until very recently, there are some very new developments in the hearing aid industry that is incorporating AI. And this is a, you know, this is a disruptive technology. This is a new innovation in hearing healthcare.

SPEAKER_01 1:15

Hello, good afternoon. I'm Dan Osterweil, co-director of the Intensive Course in Germanic Medicine and Border View at UCLA. And it's a great pleasure to have this conversation with Dr. Joshua Chodosh, a good friend and geriatrician, that will talk to us about hearing loss and aging.

SPEAKER_03 1:40

Thanks so much. I'm happy to be here. It's great to have this opportunity to talk with you, Dan. So I am a clinical geriatrician and health services researcher here at NYU Langone Healthcare System in the Grosswood School of Medicine, where I'm a professor of medicine and population health, and I also direct our division of geriatric medicine and palliative care.

SPEAKER_01 2:16

And it's really great that you could make the time to uh share with us some of your pearls of wisdom on this topic, which has been an interest of mine for many, many years, and now even more as I get older into my later years. And I won't use any jokes here to demonstrate the issues of hearing, but as far as as you are concerned, and I see that among your responsibilities actually being a professor of population health. So what is the big deal about hearing and aging or hearing at all from the population health perspective?

SPEAKER_03 2:57

It's an enormous deal on so many fronts. First, it's it's an incredible level of prevalence. You know, we're really talking about age-related hearing loss, not all hearing loss, not congenital hearing loss, which is a worldwide problem. But age-related hearing loss, um, if you're in the group that's 80 years and older, you probably have a 75 to 80 percent probability of having significant enough hearing loss that you would benefit from some adaptive device. And what's what's equally important about that is that if you're not benefiting, that means that your hearing loss has impacted your ability to communicate, your ability to interact with your peers, with your family uh reliably, um, with clear information, um that you've you're enjoying your relationships to their fullest because your communication is is easiest. Um and so it's a it's a disability. It's it's a disability, and it's a it's a functional disability and it's a social disability.

SPEAKER_01 4:02

So so why, you know, uh since Medicare has kind of put out this uh annual wellness visit um and uh insisted that during the regular encounters people ask whether people fail, or people, and all those uh questions that we have uh worked very hard to introduce into mainstream, why nobody ask about hearing?

SPEAKER_03 4:25

They should. I think part of the problem is if you're a if you're a Medicare uh insured person, you can go to see an audiologist. Medicare will cover that. But then what? Now, if you're going to bend if you're gonna qualify for a pair of hearing aids, you could be, you know, easily on the cheaper, cheaper level, three grand, but maybe as much as six thousand dollars out of pocket cost for a pair of hearing aids. Um, you know, if you have Medicare managed care, those costs will often be less because more and more plans are offering a benefit. But most of those plans that I'm aware of don't cover the full cost of hearing aids. And so it's a it's a big expense. Uh and hearing aids, of course, aren't the only answer, but I think too too often audiologists don't necessarily offer other strategies, and they should, because there are many things that one can do if they have hearing loss, not just hearing aids.

SPEAKER_01 5:24

Would you like to uh expand on that a little bit?

SPEAKER_03 5:27

Sure. So, you know, there's it depends on your level of hearing loss, but if your hearing loss is is in the mild range, you might you know you might want to use some sort of strategy that's situational. You know, you might not need your or your hearing to be perfect all the time, but if you're going to do a particular thing, you might want, you might want to have an advantage to help hear more easily. And so, for example, um, you know, earbuds that are connected to a uh a device, you know, not to not to be, you know, promote any sort of commercial entity here, but there are there is software and there are programs and devices that if you're wearing the you know the usual um earbuds that we use to listen to music or even a phone call, you could use your phone as a as a directional microphone to listen. Um the other thing that is true now in I think pretty much across the board of smartphones is closed captioning, which is really helpful if you can, if you and and quite accurate, you know, to pick up what somebody is saying and turn it into visible words on a screen for you. That's that's another strategy. Um and also just teaching you about strategies. Don't try to have a conversation in a crowded room with a lot of noise. You know, if you're if you're going out to if you're going to go out to eat somewhere, think about the environment you're going out to eat in so that maybe you can enjoy that conversation and not feel frustrated because the acoustics are so bad. So let me just one example.

SPEAKER_01 6:58

Sorry, so let me actually interject here with a question. Do you suggest that it's if I'm hard of hearing and I have a phone and earbuds, and I go to a restaurant with you, that I'll put my phone in the middle of the table and I can benefit from that, or the background noise will kill it?

SPEAKER_03 7:14

I I think you'll still pick up the background noise. Um so I don't I don't think necessarily it's a great thing in a noisy environment. But honestly, neither are hearing aids. Until very recently, um, there are some very new developments in the hearing aid industry that is incorporating uh AI. Uh and I know of one device in particular. I have not tried it myself yet, but I will, um, because it sounds extraordinary. Because it it really does uh address the single noise issue, it does filter out background noise. Um there are there are AI strategies now where you where it can recognize the voice of the person that you're looking at and and filter out the other noise. Um and the people that I know in particular who are involved in this company and are promoting this um are really ecstatic about this. This is a this is this is a this is a you know this is a disruptive technology, this is a new innovation in hearing healthcare.

SPEAKER_01 8:20

Interesting, because a friend of ours just said that her best friend is flying to New York because she heard about it and she has to go in person because nobody else uh provides another.

SPEAKER_03 8:30

That's correct, and I bet I know where where she's going. So again, I'm not I'm I'm not here to advertise and people write in all kinds of you know questions about this. Um I'm not on their, you know, I'm not on their board. I don't, I don't, so I'm and I'm and I and even if I were I wouldn't use this to you know to do a correct promotion. And I honestly and I and I haven't tried them myself, so this is you know, right now I think this is uh a little bit along the lines of here say, but I think I can tell you that what's happened, and they're not the only ones. This is not, you know, this is not an exclusive technology, but they've they are engineers, um, and then they looked for audiologists to to to to run their their you know their storefront. Um but they're engineers and they use that engineering background to to build a better mousetrop.

SPEAKER_01 9:19

Sounds very, very intriguing. Let me ask you, since you've been flying all over the world and talking about hearing loss and other things, have you picked up anything that uh Europe or Asia uh is a little more advanced in its approach to uh uh dealing with hearing loss than uh we are here in the States?

SPEAKER_03 9:43

I don't, you know, that's a good question. And first, you know, it sounds like I'm a world traveler. I you know, I've gone a few places around the world, but certainly not all over the world. Um and I, you know, I don't I think the we, you know, I once was involved in a conference and we had people, you know, we had a speaker from Australia, we had someone else who I think was was from originally from France, uh uh someone from Canada. And I don't have the sense that the the that things are very different, except that I think that there's group perhaps because of the more socially minded and and different healthcare systems that access may be a different issue in in some of these other countries, as maybe cost. Because here, you know, as I mentioned, the these devices are you know can be extraordinarily expensive.

SPEAKER_01 10:31

And what about those loops that uh in auditoriums and in in public places great?

SPEAKER_03 10:37

Those are those are FM frequency uh you know wired into the into those rooms, and but but usually you either you know you know like if somebody was going to a you know a theater event or something that they would get a headset, and that headset would would hook into that loop. Um but if you had if you had a pair of hearing aids, um, and usually if you have a pair of hearing aids, you've got an app on your smartphone, and and you could then connect to that loop from your hearing aids.

SPEAKER_02 11:07

Yeah.

SPEAKER_03 11:07

And so one of the one of the one of the the nice things about hearing aids, I think, and not I'm not a I'm not an overall promoter of hearing aids, I think they're not for everyone, and they often aren't aren't adequate. But one of the best things about hearing aids, at least as a burgeoning technology, is bluetooth is built-in Bluetooth. So that you can program these directly into your phone. So when you get a phone call, that you know you have to pull your hearing aids out, and you have to first put in a earbud if you want to listen that way, but you can listen directly from your phone. I will tell you that even in some of the better hearing aids that I've tried, um, the Bluetooth is not nowhere near perfect. And I know that Bluetooth, as a technology, is improving every day, so that's gonna get better, and I think it's gonna get better really fast.

SPEAKER_01 11:52

Let's switch gears now to an area that um has a lot of myths and misconceptions, and this is the relationship of hearing and cognitive impairment. Uh does hearing is one of the risk factors for dementia?

SPEAKER_03 12:09

Well, if you if you listen to what a lot of people are saying, you think it might be. Um, I think for a long time in the literature, from an epidemiologic standpoint, there have been strong associations between hearing loss and cognitive impairment. Um, but I think we have to think about the company that it keeps. Um I don't think there's much question that if you have poor hearing and you're cognitively tested, and that hearing has not been properly addressed, you're gonna do poorly on those cognitive tests. So already that's that's one instance. I think the other the other thing that happens is when you have hearing loss, very often, because it's harder to interact with other people, because of the stigma of hearing loss, you uh may self-isolate. Um you've you've had one too many experiences where people got upset with you. How many times do I, Dan, how many times do I have to how repeat myself, you know? And and that people conflate poor hearing with poor cognition, when in fact they're two very different functions. Um and so people socially isolate themselves, and we know that social isolation in and of itself has some very deleterious health effects, one of which may be cognitive impairment. And then and then lastly, I think that we underappreciate the plasticity of brains, and when you don't use uh certain parts of your of your brain, those parts, particularly as you get older, is has greater likelihood of having atrophy. So that even some of the studies now that are looking at hearing correction and and and brain morphology and and respective uh atrophy in specific brain regions, may not be the kind of atrophy that we see from from inflammatory states where there's actually neuronal cell death, but it might be the atrophy of of lesser use. Just like we you know we see other other areas where people have really used very specific cognitive functions where they may have they may have more development in those in those brain areas.

SPEAKER_01 14:24

So it's sort of use it or lose it type of thing?

SPEAKER_03 14:27

Maybe to some extent. I mean, certainly if you took a group of people and you and you socially isolate them for six months, and then you give them uh you know a series of cognitive tests. Nobody's ever done this study, of course, but I but I would I would hazard to say that they probably will do more poorly. We know, at least anecdotally, with our patients, when they are then engaged with their family, when they have more to do every day, they do better. We see it. They're more alert, they're more engaged, they're smarter, they're more, they're more capable from a cognitive standpoint than if they than if they haven't, uh than if they've been you know very isolated and and if you will understimulated.

SPEAKER_01 15:12

So what you were would you recommend a family or uh with the loved one who have mild to moderate uh hearing loss that have also uh significant cognitive impairment as far as amplification?

SPEAKER_03 15:26

Well, you know, there even more so I I worry because we just made that cognitive function a whole lot worse. Um because not only did I not you know remember what we talked about 10 minutes ago, but I never had the opportunity to really encode the information. And there's an important piece there that I think people don't think about, which is which has to do with cognitive load and cognitive bandwidth. If I'm working really hard, if let's say I'm actually engaged, too often those folks are checking out, you know, it's just too frustrating. I'm gonna sit there, I'm gonna smile, I'm gonna nod my head, but I'm not gonna clarify what you're saying because it's too frustrating, it's embarrassing, so I'll just kind of play along. That's what some of us would call checking out. Um and so if you're you know, if you're not, if you're working really hard, you know, alternatively, not checked out, you're working really hard to understand what somebody is saying, you're not you don't have the same ability to encode the information that you that you've been given, because you're really thinking about mostly about the words, and did you get the word, rather than in a more relaxed way, the concept that you're now thinking about and working with and encoding it in your in your normal conversational patterns so that you actually have something later to retrieve. If you don't encode the information, you sure can't retrieve it. So so I think that's an area where somebody with cognitive impairment, whether they have cognitive impairment or not, might benefit. But you know, there's other there are other ways too that we don't well educate families. You know, one is when you're having conversations reducing the background noise, making sure that that person can actually see you. Maybe they have visual impairment too, making sure that there's that the area is well lit, that your face is well lit, because all of us use facial expression and more importantly, lip reading to understand, to fill in the gaps where we don't quite hear things perfectly. None of us hear everything perfectly, because none of us probably speak with perfect addiction unless we are really trying and emphasizing and trying to speak that way. Um, so that's that becomes uh a potential uh piece that one can do behaviorally that may improve one's communication ability and mitigate some of the some of the hearing loss. And then it's also you know, how do you talk to somebody? Are you like super fast talker and you're mumbling and you're you know blah blah blah blah blah blah. You know, of course you just made it harder for somebody to understand you. It'll be hard for anyone to understand you, but now it's doubly hard for somebody with hearing loss. So families being aware of this is really important. And then we haven't talked about this, Dan, but you know, another, another um, I think very useful strategy that we've had a lot of uh traction with uh is the use of other kinds of amplification devices. You know, people sometimes call these pocket talkers because it's usually something that can sit in your pocket and it's a headset that's hardwired to a device. It could be earbuds or it could be a headset. I think the advantage to a headset is the noise cancellation and the directional microphone in that in that device can make an enormous difference because you can take it on and put it on and take it off whenever you want. You don't have to have the same level of dexterity to manipulate, you know, as you might with a small pair of hearing aids. Um they can be a little harder to get in or take out if you're not sure just how to do it. Um so that's a that can be a very useful device. And they often you they come with a long cord. So imagine that you're sitting on your couch, but the television is 20 feet away, you can move that microphone closer to the television, you're still listening, and you've got directed sound. And that that can make uh an enormous advantage, you know, enormous benefit for people who have you know mild to moderate hearing walls.

SPEAKER_01 19:25

That's a great point. You know, um I think I heard that you did some work on utilization of emergency room services uh for people who have uh hearing loss. Can you comment on the other thing?

SPEAKER_03 19:38

Yeah, we we did and we're still doing it. We're in now four emergency departments across the country in the uh in the VA system, uh hoping to actually do this in a in a larger pragmatic trial in the non-VA system. But basically that's a that's a project that screens individuals for hearing loss using a uh you know a verbal survey, you know, a question and answer, simple question and answer survey. Um and if people meet criteria, which is self-reported difficulty with hearing, uh then they're they're offered uh one of these hearing amplifiers to use during their emergency department visit. We did this at a randomized controlled trial as our first foray into this work. Um, and so we randomized people to get these pocket talkers, either at the beginning of their visit or at the end of their visit. Everybody got one because we wanted to be able to serve to interview them at the end of their visit and not have hearing loss be an impediment to that survey. And and and the kinds of things that we found were not only were people reporting that the listening was easier, um, and uh that they uh uh and that they there was there was a greater sense of enjoyment or satisfaction with their visit, but we also heard the same thing from the healthcare side, from the physicians and other staff, that they loved it when these patients actually could hear them more easily. Their work was easier. But then perhaps most importantly, is we saw a huge difference in people expressing that they knew what was wrong with them when they left the emergency department, what diagnosis they had. Imagine maybe only a third of the time, 30% of the time, somebody asks you, What did the doctor say was wrong with you that you actually knew? Versus you know, three quarters or you know, higher uh numbers of people who left the emergency department who could say what was wrong with them as a result of having one of these amplifiers. And then the last thing that we we had as a signal, we didn't, this was not powered for this outcome, and we've done additional work now that we have not analyzed yet with greater numbers, and hopefully we'll have enough power to detect the difference. Is that we saw a threefold difference in uh three day emergency department returns. So that if you didn't Have one of these amplifiers, you were three times more likely to be back in that emergency department. Um, it was it was nine percent versus three percent were back in three days.

SPEAKER_01 22:10

Oh wow.

unknown 22:13

Didn't have a pocket talker, and three percent for those who did. So that's that's a pretty, and again, too small to be statistically significant.

SPEAKER_03 22:22

I think we had 160 patients roughly in that particular trial. It was never powered to do that. It was it was pilot work, so really we really weren't talking about statistical significance anyway. Um, but it's pretty hard to ignore those those differences.

SPEAKER_01 22:39

It makes perfect sense. Now, were you successful in having uh those pocket talkers or similar introduced into your own clinical setting? So every clinician has those in case they encounter somebody who uh is hard of hearing?

SPEAKER_03 22:55

To to a fair degree, you know, we we certainly use these in our ambulatory clinics, I think, quite well when people remember to do it, because that's the other piece, is that I think we have not yet built into our clinical decision supports the proper nudges uh and and even the proper screening to know that this is a person with with hearing loss, and you should be using some sort of uh amplification strategy if they don't have hearing aids and those hearing aids are aren't working so well. Um but we do that. Um I think on the inpatient side, I I think it's they're readily available again when people think of it. Usually it my experience it often requires a geriatric consult to think of it, and then they get one of those amplification devices. We need to change that, and we I think we'll get there, but there's a number of steps I think that we have to get into place to make that a reality.

SPEAKER_01 23:52

What you just said reminds me of a story from uh my time with Sage, where I had a couple came from Florida, she was a petite lady, very hard of hearing, and her husband had a modern degree of dementia, but he was very active and spunky, and she was coming into the clinic and couldn't hear a word of what I was asking. I said, How is Saul doing? And she says, What? And twice he said it, and then Saul says, He is asking you, how am I doing? So that made an impact on her, and she uh agreed to get one of those hearing aids uh with this big uh remote that she was able to put on her belt uh and and and adjust it. But whenever she was coming to the clinic, she was adjusting it to the lowest, so it was always a challenge, but it's it's it's really uh a fascinating uh challenge. Yeah.

SPEAKER_03 24:51

Anything else that would like to uh what we you know what we haven't talked about are cochlear implants, yeah. And uh, you know, and again, because they're not they're not utilized enough, I think. Um, and those are really the best strategy for folks who have you know a higher level of moderate to most importantly severe hearing loss, where amplification isn't going to fix the problem. And one of the really I have a colleague who's a who's a a skull-based surgeon, odolaryngologist, um who does a lot of cochlear implants, and he's taught me that what happens when you raise the level of amplification too high, you distort the sound. So that's that's a technological problem, which I think may have been fixed to some degree by this by these new hearing aids, by this AI incorporation's this higher level of engineering. Um, but even so, there are instances where you know you've got to get to the hair cells, you know, you've got to get to the cochlea to stimulate it directly to the cochlea because it isn't gonna work otherwise. And I know from from clinical experience, this has made a huge difference in the quality of life for patients. It does require a learning curve when they when they when they're given one of these. Um I think a lot of people didn't shy away from this because it was like brain surgery. And in fact, now we do these as same-day surgeries. It does not require anesthesia, um, and uh and it's very well tolerated. Uh, and there are a whole lot more people who are who are getting, who are sticking with their hearing aids, maybe being frustrated with them, constantly going back to an audiologist to have them adjust it, when in fact what they really need is is a different strategy, and in this case, perhaps a cochlear implant. One of the things that is not done typically in the audiology suite is word recognition. A lot of audiologists will use what's called a real hear, which is basically based on your audiogram, they'll take those hearing aids and using it using computer adjustments, set them to the proper frequencies to match your audiogram, and then that should give you good listening ability, right? But what's not being tested is a sort of a real world application, which is when you have the hearing aids in and I and I say specific words to you, what is your what is your uh your hearing accuracy? Because I think in too many instances you'll find that they're not recognizing even 50% of the words that are being spoken. Well, that's a hearing aid that's not that's not adequate for you.

SPEAKER_01 27:37

Now, as far as the adjustment to cochlear implants, do you have an idea of what are the highlights of the most challenging parts in this what you call learning curve?

SPEAKER_03 27:48

I mean, I think it's just it's a different sound to get used to. Um and so I think it takes that that I think one has to set proper expectations so that when you first you know attach to the external device and you're you're you know you're listening to this the this noise, let's call it noise, that it you don't expect it to be what you would what you would normally expect to hear. And not, you know, not being a cochlear implant user myself, it'd be hard for me to explain what that is, but I think the sound has a different quality.

SPEAKER_01 28:23

Yeah.

SPEAKER_03 28:24

Um and that quality takes some getting used to.

SPEAKER_01 28:26

Yeah, uh a friend of mine who is also a neighbor and a neurologist had a cochlear implant, and he said that he's an avid music listener, and listening to the orchestra and listening to things that he knew, you know, the tunes, was extremely challenging. And it took a while uh to get to it.

SPEAKER_03 28:46

What did he get there?

SPEAKER_01 28:47

I think he got there. It took him about six months.

SPEAKER_03 28:50

Yeah, six months is about what I'm I'm accustomed to hearing in terms of you know the strategy for this. But just imagine someone that couldn't communicate at all, other than you know, closed captioning or sign language or whatever else, and now can actually communicate and communicate pretty well. That's that's like an enormous game changer for someone in quality of their own life.

SPEAKER_01 29:15

Now, not to make it look ominous, but uh when a physician doesn't pay attention to hearing, um what injustice or what are we missing as far as the patient is concerned?

SPEAKER_03 29:29

But what's the physician, what's the physician missing?

SPEAKER_01 29:32

If if the physician doesn't pay attention to hearing, it's like you know, if you miss blood pressure checking on a patient, you know, there's a risk there. There is a what kind of risk uh he is exposing the patient to if he doesn't pay attention to that?

SPEAKER_03 29:46

Well, as much as a wasted visit. Because depending on how probing the questions are, the you know, the physician might get socially acceptable answers without necessarily a lot of content, um, or the wrong the wrong answer because the question was misunderstood because it wasn't heard properly, because a couple of words were missed, and they still answered the question because they got some of it, um, and uh and and less attention because again, it's about it's about this, you know. Look, when you go to a doctor and you leave the doctor's office, it's hard enough to remember what that person just said to you, because that for from a standpoint of a patient, that's usually kind of a monumental experience, right? There's a lot, I think physicians don't realize there's a lot of emotion that's happening for many patients when they walk in to see a decision. It's not just a walk in the park. You know, it's a big for patients, most patients, at probably at any age, it's a big deal, right? What are they gonna find? What are they gonna tell me to do? Am I gonna feel differently about myself after this visit? Because now I'm gonna walk out with a different diagnosis or a new diagnosis, right? All those things are operating, and now I'm sitting there explaining to you what's going on, and I'm giving you three recommendations or five recommendations or whatever it is. If I'm really good, maybe those recommendations are being written down, so that will help, but we don't really have any opportunity to clarify even if you understood what those recommendations were. Maybe, maybe I have to adjust them because you're gonna say, you know, I don't know how to do that, or I can't do that.

SPEAKER_02 31:25

Right.

SPEAKER_03 31:25

Um, but I'm not getting that feedback. So it's a it's a wholly inadequate visit. And you know, AI is not going to fix that. The AI will help a little bit. We now have in our institution we have what's called ambient AI, and I just listen, I just heard you know, a presentation yesterday that was kind of jaw-dropping, where where the ambient AI will produce not just the note, but it will take out of that note the specific patient-specific recommendations and put it into lay language uh and provide and and pick anything that was an order that was given, that maybe didn't the physician didn't include in whatever they might have done with the if they handed a piece of paper with here's you know, or printed something, here's what I want you to do. So I think that's gonna that's that's that's a game changer. But if you're a patient that doesn't hear well, and now you got this, now you unless you can look at this and now spend the next five to ten minutes that you don't have asking questions about those things because now you understand because you're looking at them, assuming you've got reasonable vision, um, you know, you're gonna you're gonna miss out on a lot. And so that visit is gonna be has the risk of being far less effective. And some of those things could be pretty important, like making sure you show up for that that uh examination, or making sure you go to the pharmacy to pick up a medication that was ordered for you, or that you take it in a certain way, you know, all those things, right? Or certain red flag symptoms to look for to make a phone call.

SPEAKER_01 33:03

Those are great points. And actually, when you look at the protocols or the workflow in clinics, this handout after visits, you know, summary is handed, is handed uh, you know, in the window when you leave. So there is really no opportunity to uh to talk about it. So it's it's that's a fruit for thought, too.

SPEAKER_03 33:22

It's the same issue, right?

SPEAKER_01 33:23

Yeah, it's the same issue. So I know just for the benefit of the listeners that you are going to uh speak at our intensive course this this coming fall, and I'm sure that you are going to touch upon many other points that we have not touched upon. And I really appreciated this chat because I think it gives an opportunity to explore an area that is, I think, neglected. And I remember and I remember that you talked about recommendations of the Institute of Medicine at the time uh about hearing and hearing aids, and the fact that hearing aids right now you can get without prescription uh in certain points. What do you think that what's the potential impact on that on hearing health?

SPEAKER_03 34:11

You know, I think hearing aids that you can buy over the counter are probably helpful for a certain slice of society. Um, because if you look at those inserts, if you look at what's being provided, they're not a couple of things. One is you may not fully understand how best to use them. Um you there's still the issue of can I manipulate this? Will it fit properly? What's what's my manual dexterity? Do some some considerations need to be made for that. Um, and also they're not, there are, you can buy, I believe, programmable hearing aids now, where you do a you do an online test and that hearing aid is then programmed to your your online audiogram, but it cannot be, I mean, the it's never gonna be as accurate. And my worry is that people are gonna buy these things, and if you think, you know, right now that the statistics that I know are about three out of every seven people who are prescribed hearing aids where it's less than 50%. And you just spent a lot of money to have something adorn your desk drawer. Um or you if you don't lose it, if you don't put it away somewhere and now you can't find it because you because you're not a regular user. And now you're gonna spend, you know, it's also out of Ponica, but it might be as much as I don't know what they're going now, but maybe six, eight hundred dollars for a pair over-the-counter pair of hearing aids.

SPEAKER_01 35:41

Even more.

SPEAKER_03 35:42

Um and uh and so if you if you're gonna do that, I know if you if you go through even the real year process and the audiogram, etc., when you fit those hearing aids, the first time you fit, they're not necessarily correct for you. The sound audibility is not necessarily exactly right for you. And that should be a conversation with your audiologist to make an adjustment. He'll he'll take them out, he'll stick them back in the in the holder and adjust the computer settings and try it again. So there's a there's a try, there is an sort of empirical trial and error process, and then you will go off with them if you have if you have good audiologic good audiologic care, you might go off with them for two or three weeks and come back because you know, John, they're not just right. Well, what's going on? Well, I can hear this, but then I have trouble with it. Well, let's let's seem to make an adjustment. And so, and some of that also is around getting the right kind of uh what we might call hearing rehabilitation. If you've got a good audience, like how do I use these things most effectively? And so give me some strategies. Uh, and you're not gonna get that when you buy this on LinkedIn.

SPEAKER_01 36:58

Because I I think some people think that audiologists don't have a role while you buy those things in Costco. And I totally agree with you that there are a lot of needs that uh can be um met using a professional uh in getting those hearing aids. Thank you so much, and um we'll see you in the phone.

SPEAKER_03 37:17

Look forward to bye.

unknown 37:19

Bye.