Words of Wisdom Across 20 Years

Hearts for Hearing, the workplace of your humble Tot 10 authors, is embarking on its 20th year of serving children with hearing loss and their families. This milestone has caused us to reflect on many aspects of our work including the extraordinary outcomes and achievements of many of our infants and children, some of whom are now young adults and leaders in their communities. We also find ourselves cherishing the invaluable relationships we have built with patients, families, and colleagues as well as the things we have learned along the way. This month’s Tot 10 installment highlights just a few of the lessons we have learned over the past 20 years.Hearts for Hearing, pediatric audiology, anniversary, wisdom.10. Know Your Anatomy and Physiology! Dr. J. Michael Dennis, an audiologist who specialized in diagnostic audiology and pioneered intraoperative neurophysiologic monitoring before he retired a few years ago, took great pride in his encyclopedic knowledge of anatomy and physiology of the auditory system and the human nervous system. Dr. Dennis often exclaimed that it was virtually impossible to fully understand and competently practice diagnostic audiology without a strong foundation in anatomy and physiology of the ear. He warned students and clinicians that clinical mistakes were far more likely to be made by those who had not mastered the structure and function of the normal auditory system. He declared that it was impossible to become a master clinician without first mastering anatomy and physiology. Over the years, his words have rung true time and time again. Understanding and diagnosing auditory neuropathy spectrum disorder and explaining it to families is essentially impossible without an understanding of the anatomy and physiology of the cochlea and nervous system. Identifying site of lesion from the interpretation of ipsilateral and contralateral acoustic reflex results is much simpler when the underlying anatomy and physiology is understood. Fully understanding the prognostic significance of imaging results that suggest a dysmorphic cochlea or aplastic cochlear nerve only occurs for audiologists who can use their knowledge of peripheral auditory system anatomy. Do you want to reach your full potential as a pediatric hearing health care professional and optimize the services you provide for children and their families? Then you must first master anatomy and physiology of the auditory system and human nervous system. 9. Never Miss an Opportunity to Collect Data! In one of the early years of Hearts for Hearing’s history, Dr. Gus Mueller served as a keynote speaker at the Oklahoma Speech-Language Hearing Association annual meeting. True to form, Dr. Mueller delivered an excellent presentation on the fitting and verification of modern hearing aid technologies. Although we learned quite a bit from Dr. Mueller’s presentation, he dropped quite possibly the most insightful pearl over drinks that were enjoyed after the conference. When we asked him for advice on how to pursue the same kind of success he had achieved in the research and publishing arenas, he noted that he never missed an opportunity to collect data. While leading a team of audiologists in the United States Army at the Letterman Army Medical Center and then as Chief of Clinical Audiology at the Walter Reed Medical Center, Dr. Mueller challenged his colleagues to consider setting up clinical research studies to provide the answers and solutions for questions and challenges they encountered in the clinic. His mantra to his staff was, “Every patient who walks in our door is a subject; you just have to design the right study.” He encouraged his team to identify ways in which they could track and summarize the data they collected while rendering clinical services. He saw the introduction of new hearing technologies as an opportunity to “put it to the test” to determine if it really provided his patients with the benefits claimed in advertisements. Of note, in 1984, Dr. Mueller’s clinical staff at Walter Reed had 10 papers accepted for presentation at the American Speech Language Hearing Association Meeting! Today, ethics boards (e.g., institutional review boards [IRB], etc.) require clinicians obtain approval prior to completing a clinical research study. Clinicians must also seek approval from an IRB to ensure they are exempt from formal oversight during the review and summary of clinical data, and all clinical data must be de-identified before being shared with others. However, Dr. Mueller’s advice rings true today even more so than it did almost 20 years ago. Many of our profession’s most prolific researchers are approaching retirement. In the age of over-the-counter hearing aids, online hearing tests, listening training apps, etc., hearing health care professionals must prove our value to our patients and third-party payers. The viability of the profession of audiology is dependent upon our ability to practice evidence-based care and quantify the value of our services. Dr. Mueller is still right. We must never miss an opportunity to collect data to support the work we do and advance the care we provide for the patients we serve. 8. We Have to Know this Stuff Works in the Real World! Dr. Marlene Bagatto has written extensively on verification of hearing aids for infants and young children. Over the past decade, Dr. Bagatto has also reminded us of the need to ensure that we are highly confident in the validity of the services we provide for infants and children with hearing loss. Dr. Bagatto spearheaded an effort to develop a protocol to validate our services by evaluating the real-world outcomes of the children we serve. She encouraged us to use assessments of functional listening behavior (e.g., LittlEARS, PEACH, etc.) to ensure our youngest patients are responding appropriately with their hearing technology in real-world settings. She reminded us that, whenever possible, we should compare the results of the measures we administer to normative values available for the population we are serving. Indeed, results of the LittlEARS and PEACH questionnaires may be compared to normative values obtained for children with typical hearing of a similar age, and Dr. Bagatto also worked with a team of colleagues (Sheila Moodie, Susan Scollie, et al.) to create a chart that provided normative values for the speech intelligibility index (SII) as a function of degree of hearing loss. Once again, her message was clear. We must ensure that our services stack up favorably to evidence-based expectations for real-world situations. Moreover, when the Ontario Infant Hearing Program recently acquired new diagnostic ABR equipment, Dr. Bagatto led an effort to ensure the new equipment was providing a similarly accurate estimation of infants’ behavioral hearing thresholds as the tried-and-true equipment they had used for many years. “We use these ABR systems to make decisions that are really important for a baby’s life,” Dr. Bagatto declared, “and we must make sure it works!” 7. If It Does Not Repeat, It is Not Complete! Dr. Jay Hall, a world-renowned diagnostic audiologist who has authored numerous journal articles and textbooks, has a unique gift to be able to take complex information and present it in a way that is simple to understand and remember. His textbooks on auditory-evoked responses are truly must-read materials for audiologists who complete auditory brainstem response (ABR) assessment with children or adults. We could literally write pages upon pages describing everything we have learned from our time with Dr. Hall and from his books and the presentations we have consumed. For now, we will stick with one great example. To enhance the audiologist’s ability to accurately interpret auditory physiologic responses, Dr. Hall extolled the imperative need to ensure the repeatability of auditory responses (e.g., highly overlapping ABR waveforms obtained at the same presentation level, otoacoustic emissions that replicate across two runs, acoustic reflexes that have repeatable amplitude and morphology at the same stimulus level, etc.). To drive home the importance of this fundamental diagnostic principle, Dr. Hall has been fond of saying, “If it does not repeat, it is not complete!” He has also been known to say, “If it doesn’t replicate, you must investigate!” He has even been known to say, “If it is not reliable, you may be liable.” When asked about the origin of these wise sayings, Dr. Hall offered the following: “Young folks now may not appreciate the background on these phrases. One by one they popped into my head back in early 1995 during O.J. Simpson’s never-ending trial coverage on TV as I repeatedly heard OJ Simpson’s lawyer Johnny Cochran perform in court, especially when he famously quipped... ‘If it doesn’t fit, you must acquit!’ I was giving ABR workshops regularly in those years soon after my 1992 Handbook of AERs was published, so I started to include my ABR sayings in presentations. Back then, all the attendees were familiar with the original Cochran quote.” 6. Help is Not What You Want Unless It’s What You Want When You Want It! Jan Moss served for years as a core faculty member for the University of Oklahoma Leadership Education Neurodevelopmental and Related Disabilities (LEND) program. She is also the mother of two adult children with developmental disabilities. We learned countless lessons from Ms. Moss over the years, but one of her comments stands out. She was fond of reminding health care students and professionals that “help is not help unless it’s what the family needs and wants when the family needs and wants it.” Our experiences with the families we have served have proven the veracity of this statement. When a family is dealing with food insecurity, dire financial problems, domestic violence, or several other serious life issues, then a child’s speech, hearing, and hearing aids may understandably take a backseat. Hearing needs may also be placed on the back burner for a child who is facing multiple disabilities and/or serious health problems. When new parents are dealing with depression or grief or are possibly overwhelmed by the challenges of caring for a new baby, it may seem impossible to support the child’s listening and spoken language needs. It may be next to impossible to attend in-person or virtual appointments without effective transportation or internet service. Ms. Moss’s words remind us that we are not simply treating a set of ears. We are serving a whole child as well as the holistic needs of that child’s family. Audiologists and speech-language pathologists should evaluate the holistic and most pressing needs of the families we serve. We should work with an interdisciplinary team of professionals (e.g., Infant Toddler Mental Health specialist, pediatrician, otologist, early interventionist, neurodevelopmental specialist, etc.) to make certain these assessments are appropriately conducted, and intervention is planned accordingly on a schedule that suits the needs of the family. These needs assessments should be readministered frequently across time. Many of the children we serve will not reach their full potential unless we ensure their families are equipped to provide the support that they and their children need during their children’s formative years of development. 5. How Do You Know What a Child Hears Unless You Test It? Dr. Jane Madell has repeatedly reminded us that we cannot confidently know what a child hears until we test what the child hears. She has constantly advocated for the use of an exhaustive speech recognition test battery for children with hearing loss. She has lamented the all-too-frequent clinical practice of only evaluating word recognition in quiet at a conversational level in the binaurally aided condition. She contends that aided speech recognition should be evaluated in multiple conditions including: Word recognition at a conversational level (e.g., 60 dBA) in the right and left aided conditions and in the binaural condition unless ceiling levels are encountered in the binaural conditions Word recognition at a presentation level consistent with soft speech (e.g., 50 dBA) at least in the binaural condition and ideally in each monaural condition Sentence recognition in quiet at least in the binaural condition to ensure children possess the language, vocabulary, and auditory memory to repeat the words they hear in connected discourse Sentence (or word) recognition in noise at least in the binaurally aided condition at an adverse signal-to-noise ratio (SNR), which varies depending on the child’s ability and may require sequential testing multiple SNRs; e.g., 0, 5, 10 dB SNR); ideally, sentence recognition in noise will also be completed in each monaurally aided condition. Of course, all this testing cannot be completed in one test session, but we do strive to complete this exhaustive battery of speech recognition measures across multiple appointments scheduled throughout the year. In many instances, we have been able to provide better intervention for a child after identifying the child’s needs from the comprehensive speech recognition testing that we conduct. 4. Get a Life! Dr. Stephen Painton is quite possibly the most skilled hearing aid dispensing audiologist we know. He expertly balances the science and art of hearing aid selection, verification, and validation to aptly meet the needs of his patients. He has published fairly extensively on the topic of hearing aid dispensing in trade and peer-reviewed journals. He is also one “heckuva” a tennis player! Most importantly, he is an outstanding human being who has made a life-changing impact on countless students and who simply makes the day a little brighter for every patient, colleague, and student he encounters. On numerous occasions, he has commented that he realizes he could have spent more time in the research lab and at his computer cranking our publications. However, as he recently stepped away from full-time employment, he expressed that he has zero regrets. He has noted that he is more than happy with his decision to focus on the relationships he has built with his students, colleagues, patients, friends, and family. He takes pride that he routinely whips foes half his age on the tennis court. As he looks at his successful career in the rearview mirror, he is glad he chose to strive for balance in his work/personal life. He even noted that he thinks he was better able to take care of his professional responsibilities to patients and students because he was cognizant of taking care of himself physically, mentally, and emotionally. Sometimes, the decision to leave work a little early to get in a tennis lesson or match positioned him to be in a better state of mind to take care of a patient the next day at work. Although our work is vitally important, Dr. Painton reminds us that we need to get a life! 3. Find a Need and Meet It In 1973-1974, a rubella outbreak in Halifax, Nova Scotia, Canada, created an unexpected caseload of more that 30 infants with hearing loss for two young audiologists, Richard Seewald and Patricia Stelmachowicz. At that time, there were no evidence-based prescriptive hearing aid gain/output targets for children and there were no hearing aid analyzers that allowed for the completion of probe microphone measures. Moreover, body-worn hearing aids were the primary style of amplification available for children. Seewald and Stelmachowicz did the best they could to meet the needs of those babies under less-than-ideal circumstances. Then, they both went back to school and earned doctoral degrees in audiology as they studied science-based procedures for fitting amplification for infants and young children. Eventually, Dr. Seewald collaborated with Dr. Mark Ross and others to create and refine the Desired Sensation Level (DSL) Method for pediatric hearing aid fitting. Legend has it that Dr. Seewald and his son even pecked out some code to generate the initial version of DSL on the first model of computer released by Apple! Today, DSL v5.0 is used around the world to select, fit, and verify hearing aids for infants and children with hearing loss. We once had the honor and privilege to have lunch with Dr. Seewald and discuss his profound contributions to pediatric hearing health care. Despite his many accomplishments, Dr. Seewald might be one of the most humble and kind individuals we have ever met. When discussing his development of DSL, he matter-of-factly stated, “I just saw a and I I to do everything I could to meet it.” On the that may seem a simple statement. However, his words have our work at Hearts for we the needs of our patients, our team our and our and then we set out to develop new and and ways to meet those needs. 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It’s all about the you to all the colleagues, friends, patients, and families who have the care we have provided at Hearts for Hearing over the past 20 years. You have our and have us to make the next 20 years even better than the

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