Role of the Audiologist in Cognitive Screening: Interview with Dr. Fred Ma and Dr. Ardeshir Z. Hashmi

Amyn Amlani 0:09 Welcome, my name is Amyn Amlani and I have the privilege of serving as your host. The role of cognitive screenings in audiology has been and continues to be a topic of discussion. In this special edition of This Week in Hearing which is sponsored by Cognivue, I am joined by two distinguished physicians who have experienced in the diagnosis, treatment and management of persons with cognitive decline, and will share their thoughts on the topic of cognitive screening and the role of the audiologist. So, welcome, gentlemen. Dr. Ardeshir Hashmi 0:39 Thank you for having me. Dr. Fred Ma 0:41 Thank you for inviting me. Amyn Amlani 0:42 Absolutely. So let’s start out with a little bit of an introduction. So Dr. Ma I’ll start with you, Dr. Fred Ma, is the chief medical officer and Senior Vice President at Cognivue. Can you share with the audience a little bit about yourself, please? Dr. Fred Ma 0:58 First, thank you, man for the invitation. My name is Dr. Fred Ma. I’m a Senior VP and the CMO of Cognivue Inc, located in Rochester, New York, we’re the neuroscience company developed and manufacture the cognitive assessment device for mild and early stage of cognitive decline. So my background, I was trained a neurosurgeon and a neuroscientist with 40 years experience including neurological practices and then also the research in pharmaceutical and medical device arenas as an executive. So my passion is really to find good tools for early, early stage of cognitive decline, to help to build a process of diagnostic assessment for primary care, neurological and the non-MD, MD channel and the overall healthcare providers to give them the tools to prevent the developments of dementia and Alzheimer’s. Thank you for having me. Yeah. Amyn Amlani 2:16 Oh, wow. That’s That’s tremendous. We also have Dr. Ardeshir Hashmi, and he is the Endowed Chair for Geriatric Innovation in the section chief of Geriatrics at Cleveland Clinic. So Dr. Hashmi, would you please share a little bit about yourself? Dr. Ardeshir Hashmi 2:32 Sure. Thanks again for having me. I’ve, before joining Cleveland Clinic, I’ve been, you know, at Harvard in Boston at the Mass General Hospital where I was in a similar leadership role. And then prior to that, training at Yale and Harvard. And so my area of initial area of interest is aging and technology, especially as relates to my role as chair for geriatric innovation at the clinic. We are within the Institute for Population Health our Cleveland Clinic community care as we call it and our geriatricians are all consultative, successful aging specialists. We’re at 10 different sites across Northeast Ohio, outpatient, and then about three different inpatient sites. And then with consultative links to Florida and Toronto and a little bit internationally at Cleveland Clinic, Abu Dhabi in London. So that sort of emerging work in my in my area. Amyn Amlani 3:25 Wow, again, two distinguished physicians here on our panel today to talk about this really interesting development as audiology starts to look at cognitive screening as part of it as part of the management and treatment of these individuals. So as we get started here, you know, what is Dr. Hashmi the professional scope of the physician when it comes to cognitive decline and dementia? Dr. Ardeshir Hashmi 3:52 Excellent question, Amyn. I think it’s a very dynamically changing definition. And it needs to change because the, the challenge of cognitive impairment and dementia just nationally and even globally, is immense. And so it can no longer be the province or domain of a select few highly trained specialists, if you will, in cognitive impairment. It needs to be a team-based approach. And I think that that scope is increasing to, you know, a diversity of different specialists, including audiologist, geriatricians, and others, who can see multiple facets of this very challenging illness. And, and the multiple contributors both within the brain and external to the brain. Sort of have set up things in a way where it’s very natural for these allied specialists in the field of cognitive impairment, to really come together as a team and look at those various contributors if you will. and also potential solutions. Because I think in totality, it’s a team that’s coming together and that scope is ever changing and dynamic. Amyn Amlani 5:09 Yeah, it what’s interesting and you know, as an outside person from from within the healthcare arena, but outside of your area, we typically think of cognitive decline being treated by pharmaceuticals. And as you pointed out, it’s an expansion now, so can you talk a little bit about that, Dr. Ardeshir Hashmi 5:27 absolutely, its 30 years now, or, and more, I guess, of research, which is based on hypotheses that are very pharmaceutical driven, and, and backed in many cases, and so, you know, the results of that are very compelling, it has failed, you know, there’s 30 years of research to find that silver bullet, you know, the one medication, that’s going to pharmaceutically solve everything, and much to the real, you know, chagrin, and really disappointment of so many families, not just patients being affected by this, but families around them. And so I think that has led to multiple alternative hypotheses to challenge the amyloid hypothesis is the only one for for dementia, and specifically, Alzheimer’s, dementia. And as people have looked at those hypotheses, they’ve found different mechanistic explanations for what’s going on. And within those mechanisms, potential solutions that don’t just lie in pharmaceuticals, but lie in addressing the root causes of multiple root causes, such as hearing loss, macular degeneration, sleep disorders, vitamin deficiencies. And so I think, you know, very, not only very interesting, but I think very promising if we choose to look at it that way. Yeah. Amyn Amlani 6:49 Yeah, and as you’re talking about these external factors in these hypotheses, right. There’s the Lancet report that came out in 2017. And then again, just most recently, so Dr. Ma, can you talk a little bit about the Lancet report and how there are these modifiable risk factors that could potentially reduce the opportunities to have cognitive decline? or lessen the impact of cognitive decline? Dr. Fred Ma 7:16 Yes, yeah. Just just eluded. Dr. Hashmi’s comments, you know, in recent years, and then there are many studies that found association between the untreated hearing loss, Alzheimer disease and other types of dementia, meaning people with hearing loss are more likely to develop a cognitive problem than people who do not have hearing loss. This is an area of intense research with many unanswered questions. So that’s brought the question should we look at it this area to get more in depth research? Today there are several studies indicating people with a hearing loss may develop cognitive decline earlier than peers with normal hearing that’s surfaced by the team at John Hopkins that looked at the cognitive impaired scores over six years in a study of nearly 200- 2,000 Seniors, they concluded that those with hearing loss had a fast decline faster decline, the volunteers were all cognitively normal when research began, but the studies ended to the study, and the people with hearing loss was 24% more likely to meet the standard of cognitive impairment compared to the people with normal hearing. Therefore, Johns Hopkins, Johns Hopkins researcher predicted while this is you know, while you have this as a phenomenon, and that you know, require in depth follow up and then the non, you know, the modifiable risk factor that has to be including the hearing loss, you know, right now, that the hearing loss is become a number one which it possess 8% of a modifiable risk factor, meaning if you could mitigate the hearing loss, you could, again 9% of delayed, you know, dementia population, you know, WHO also echoed for that, WHO’s estimate about 466 million people worldwide or 5% of population living with a disabled hearing loss, that figure could expect to be almost doubled on to 900 million people by 2050. So, therefore, there are multiple research and then Dr. Hashmi mentioned a hypothesis about this, whether there is you know, connection between the cognitive impairment and declining of sensory agility. Yes, it is such early work has been followed by decades of ongoing research that was disorder said significantly improved explored a hearing loss and you know, that poor cognitive, you know, outcomes. So therefore, I think it is now a widely accepted concept that untreated hearing loss leads to structural and functional atrophy within the brain as a result of deprived auditory stimulation, and an increase in cognitive load required to process environment, you know, environmental sounds, speed and music. Right. So, to conclude, what I’m saying is, you know, based on the Lancet, the journal research have formed, the hearing loss is the number one modifiable risk for cognitive decline when identified addressed in midlife. So I think it is really meaningful for us to talk about this. Now, how can we engage the mitigation factor for assessment diagnostic and prevention? Amyn Amlani 11:10 In as you’re talking, the thing that’s going through my head is, is we’ve got a huge, huge number of individuals that have this manifestation, you don’t have the, you don’t have the number on the other side on to provide for these individuals. So now we have these modifiable risk factors. Dr. Hashmi, and you’re talking about the secondary individuals who could potentially help reduce this so that we don’t have an overtaxing situation on our healthcare system. Am I understanding that correctly? Dr. Ardeshir Hashmi 11:42 No, absolutely, absolutely are you’re well said. And I think the key thing as I was hearing, you know, both you and Dr. Ma just now is the timing of this is absolutely key, timing in multiple sort of facets of that. So one is obviously the challenge before us. But the other is within an individual’s journey. With you know, sort of early mild cognitive impairment all the way through all the fast stages of cognitive decline to the advanced stages. It’s typically unless it’s, you know, sort of in the setting of a stroke, is typically of a slow progression. The dangerous thing about this, this is happening sort of sub clinically, even before we realize it, or other people around us realize it for several decades, you know, those internal nerve, neuro, neuro-degenerative changes are already happening. And we don’t screen for it early enough. And because we don’t screen up for it for these things early enough, screening not just for cognitive impairment for all the contributing risk factors that the lancet sort of paper outlines. The the travesty that that leads to then is that by the time that people do get the attention they need, the options are very limited. Whereas if they had been identified early, and we’ve done something about the risk factors early on in the piece, addressing that would have brought into play even some of the pharmaceuticals which 100% of them are all designed to slowed the progression, none of them can reverse it. Right. So logically, what would that would entail is you pick up something early, do something about it early, addressing it holistically with all the risk factors addressed, and try to preserve that function as quickly as you can. And I think that approach is much needed. Amyn Amlani 13:28 Yeah, and as you’re saying that, you know, I go back to the earlier comment that you made that this just can’t be a narrow group of individuals, this has to be a collection of individuals. Yeah. And, you know, in audiology, we generally see, we service everybody across the lifespan, but we generally end up seeing more elderly people. Yeah, so the audiologist has a potential role, right, which is what the Cognivue device is there to help with. There’s others, right? There’s the MoCA and the Toronto scale and so forth and so on, right, the Montreal scale, but how is it that we as secondary specialists as audiologist, how is it gentlemen that we can potentially help with the reduction of this manifestation accelerating, in the roles that we have today? Dr. Ardeshir Hashmi 14:22 So I’ll give my two cents on it and invite Dr. Ma for his comments. To my mind, a little bit of reversing this, the terminology. In my mind in the next several decades, what will emerge is that the primary specialists are actually, you know, specialists such as our audiologist colleagues, because they are at the frontline, there are facets of that, that they can uncover have conversations about much earlier into the point of view, we’re just discussing. Then the secondary specialist, which I think the second line of defense almost are the geriatricians of successful aging specialists – where you’re going for the more in depth sort of assessment. But, but I think the pandemic, I mean, has taught us many, many things, one of the things that I will say just anecdotally is for all of my patients, 100% of any of my patients, and we see, you know, more than 4000 new patients with new cognitive impairment every year at our center. Every one of them, the cognitive impairment has worsened during the pandemic, not even because their risk factors changed so much, right, because they didn’t change in the last year, and not really directly because of COVID. But because of the social isolation, and mental health challenges, the depression, the loneliness that set in. And now you can imagine, you throw in hearing loss into that. And how much of a contributing factor is that to isolation, even amongst many people around you, right, just not being part of that conversation, being perhaps too proud to sort of admit to that, and or thinking there’s nothing that can be done about that, right? So that social isolation and that depression, that is a very clear risk factor for cognitive impairment, you know, documented, chronicled by many, many papers and many guidelines. And yet, we only think about the pharmaceutical aspect of it, we only think about the knee jerk response, we never think about, well, there’s contributor there, right? Why is that person being left out of the conversation? So, so I think that that, really primes audiologists and two ways to contribute: One, in raising awareness and education of, you know, their clinical colleagues in terms of their own role. But in terms of interaction with patients about this is not just sensory impairment, one dimensional, this is multi dimensional, and with a very clear, solid line leading to cognitive impairment and a dotted line leading through social isolation. So I think that’s one and I think the other is really the early, early picking up, you know, screening, the early identification, and then the subsequent communication and loopback with – how is that person doing? They’re likely to see people at the front lines much more frequently than they are to see the new definition of secondary specialist which is someone like me, for example, Dr. Ma your thoughts? Dr. Fred Ma 17:21 Yes. Yeah. I want to concur with what Dr. Hashmi just alluded to, it’s definitely, first of all, I kind of wanted to adjust this comments as the secondary specialist. You know, as Dr. Hashmi mentioned, you know, for the past 30 years, and if not longer, we failed. And we as a pharmaceutical-driven, you know, care for dementia and Alzheimer’s disease and also, we are not very successful and then to rely on totally on the primary care and neurological specialists because it’s that we’re so reactive, but not proactive. So now we need to take the proactive action that and engage the audiology, optometry as a frontline, not a secondary specialist. Because as of today, there are many scientific links and hypotheses have been proposed between the hearing loss and the cognition to explain how hearing loss may link to progressive cognitive decline and dementia. So, I summarize it with a common cause and then to cascading cause. One is, you know, is a common causes to both hearing loss and the cognitive decline sharing the same widespread neurodegenerative causes. Okay, so, therefore, I echo what Dr. Hashmi just mentioned, you know, that, the hearing loss can cascade via social effects, with the experience hearing loss cascading into social disengagement, loneliness, depression, cascading to accelerate the brain atrophy and accelerated cognitive decline and dementia. Second is cascade via auditory deprived, deprivation, auditory deprivation resulting in impoverish, you know, cortical input, causing neuroplastic changes cascading into cognitive decline and dementia that’s already proved with many many publications. Finally, the cognitive load, that’s in depth in the in the neurological research showing hearing loss causing cognitive resources to be diverted from memory function into auditory processing and adding to the cognitive load and the leading to cognitive decline and dementia. Therefore, you know, how can we exclude audio and you know, audiology from this, you know, whole picture as a secondary, you know, specialist. You can’t. So I think also you know, Dr. Hashmi and I published a survey for post COVID syndrome, brain fog, with a short period of time now we have a long longitudinal research for large population. Definitely, echoed what Dr. Hashmi just indicated, the longer you have this pandemic going, the the worse, the brain fog will impact you know, people’s life. No matter if you have a previous dementia, or you didn’t have that, you know, you didn’t have that. That’s social economic effects, plays a big role. That’s effected everything so I, you know, I encourage and I am very, very excited to move this in the frontline as a primary specialist and then to work with side by side with a primary care, geriatric care, and neurological care, to care about this. You know, the, the dementia, and then also cognitive, you know, impairment potentially, yeah. Amyn Amlani 21:28 Yeah. So it’s, it’s really fascinating what you gentlemen are saying so, you know, we’ve established the fact that this is an issue, we’ve established the fact now that there’s a need for help, right? Physicians and other health care workers working together. So now let’s start the process, if you will, about talking about how is this being used clinically? So at Cleveland Clinic, for example, how is cognitive screening a part of the healthcare system there? Dr. Ardeshir Hashmi 22:00 That’s a great question. So at the clinic, again, there’s what we’ve had, which I’ll describe first, and then where we want to sort of continue to evolve the process to so what we have in place right now is our successful aging platform, which basically means that, when I first joined the clinic, I mean, it wasn’t for lack of resources, in general, for older patients, they were it was a rich in resources, but they were very fragmented University’s sort of traditional healthcare delivery model of, you go to your, you know, physician, with whether it’s your primary care physician or specialist, it doesn’t matter, you have limited amount of time for them. So you’re forced to prioritize your top three issues that you want to talk about. And that time goes by very quickly, as we all know, from our own experiences for ourselves and for our family members. And so what happens to all of the other issues that the clinician who’s facing you, your PCP, or specialist may not have is front of mind as being really a core important issue. You know, they may be talking to you about your blood pressure and your diabetes, but they may never even get to your cognitive impairment, your hearing loss, you know, all the other sort of contributing risk factors, because it’s just lack of awareness. So that’s one the time you know, compression, if you will. And then because they’re faced with these time pressures, the the knee jerk response, then is for anything that I didn’t get to, I’ll basically refer to five different specialists, who now the patient and family have to take five different days off from work to go and see in five different places. And even within one health system, I mean, that is, can be a quite a challenge for something that is as large as you know, our our healthcare system, for example, or any, any large academic health center. And so that’s what was baseline when I sort of first started working on this in my role and wanted very much to try to, to defragment, if you will, the situation, and make sure that folks have a sort of one stop shopping experience, if you will, from multiple services all under one roof or all in a common platform. And with sufficient time, so that you’re meeting with not just an individual clinician, and that’s it, but you’re meeting with a team that is sort of tailored with precision to your needs as a patient or the needs of you and your family even right in a sort of crucial partnership. So we established in the successful aging platform with these sort of longer visits with partners like Dr. Ma, sort of with the vision that we want to take this to now is trying to put diagnosticians who have done this for a long time, in partnership with a new team that is looking at this type of license from their different vantage points, and equipping each of those members with state of the art technology, right imagine the power of that state of the art technology with the best minds the benefit is only going to be for patients and families everywhere. And so we’ve tried to do that. So the way that we are trying to reimagine that with partners like Dr. Ma and you know, Cleveland Clinic Audiology as well, is have this as a two tiered process, you know, at the front lines, you know, again, to underscore what Dr. Ma said, have the patients who are seeing the audiologist be screened with the state of the art technology with Cognivue, with the version that will give instant, you know, results back and I’ll let Dr. Ma speak more to which type of technology that is. And then would that instance sort of readout like, where do we go from here have a very direct link to the successful aging program, and come to us with more in depth assessment will be again, your state of the art technology with cognitive that is even more in depth, and have that detail sort of discussion about with you as an individual patient or family, here are your risk factors, here’s what we can do about them together as a team. And these are the individuals that you’ll meet today. Plus, you know, the relationship with us will continue until we have a very solidified plan in place. And you feel secure as a patient, family that, you know, there’s empowerment for you to take care of your loved ones and yourself. And that again, loops them back into whoever they may be seeing whether they be seeing Cleveland Clinic Audiology, whether they’ve seen us or they’re they’re seeing the pharmacist, whoever, whenever that point of contact is happening, whatever touch point, we then check in multiple times to make sure that that plan is in place. People are feeling secure, comfortable. And really, you know that we have optimized their function and whatever point of the spectrum that you first met them. So I think it’s exciting. And so that’s sort of been the Cleveland Clinic experience. Amyn Amlani 26:50 That’s incredible. So you’re you you’re sharing information, and you’re improving clinical efficiencies. I mean, the two things that healthcare absolutely needs. Just, that it’s wonderful to hear that. I’m going to shift over to Dr. Ma, you know, in terms of just very quickly, in terms of the use of cognitive screenings, what have you seen in various clinics that you work with? Dr. Fred Ma 27:17 Yeah, based on my experience, and I am a neurosurgeon myself and also have been working in Johnson & Johnson, Merck and GE Healthcare such as a C suite, I’ve been struggling, struggling working in this field struggling to look for objective, you know, timely, and also accurate precision testing, to capture early stage of a cognitive impairment. That’s what I’m looking for. So as as the both of you mentioned, currently in the most popular paper and pencil cognitive assessment that we’re using, and we have been using since ever since the early 70s, Dr. Hashmi. There’s MoCA, MMSE, SLUMS now and then the many many different batteries These three that I just mentioned was representative. However, as this battery as it happened and although is widely accepted and frequently used throughout medical societies, but its drawbacks also hit us substantially. It’s really hard to mitigate in terms of high subjectivity, you know, subject to practice effects, and intense, intensive or expensive or user sensitive. So therefore, from a physician, from a clinician, and from a neuroscientist standpoint, I, you know, take away my executive hat. So I’m looking for objective, timely, and really reliable tools that give me a quick assessment or screening way to help the clinician whether it’s in the audiology clinic or geriatric clinic or primary care, to get a sense on how the status of cognitive, you know, the function of the patient and then we can align with the other, is just like Dr. Hashmi mentioned, align with the other partners of the health care providers and to form a very efficient effective treatment plan for the patients. Therefore, the Cognivue is the one that I hope that will become on the favorable, favored tool to be widely accepted, because it possesses all this, you know, all these characters and provides, you know, the objective assessment components and remove the bias and the environment, you know variabilities, accurately record and document the various neural psychophysics abilities, and no need for extensive training and administer the test. So, it’s really benefits the physician, one, you know, the report is immediately available after test two, it can be used to refer the patients to, you know, to, to whoever needed to be referred like a PCP like neurological specialist. And the three, can be used as part of overall cognitive function and mental health evaluation, diagnostic and follow up. Amyn Amlani 30:59 Yeah, again, it’s about reducing the biases, improving the clinical efficiencies and providing information. And as you both have alluded to, it’s about having that patient then move quicker through that that health care system, so that they can be treated in a better way to lessen any issues that they may have. So that the quality of life is expanded over time, I think that’s incredible. Um, you know, and one of the things that that we often get asked, or one of the questions that often comes up, is and Dr. Ma you alluded to this as did Dr. Hashmi, you know, can these screening tools… Can they identify sensory issues, from brain issues? Is there a way to do that so that individuals can make the right treatment judgments? Whether it’s a referral. Or in the case of an audiologist, it’s the rehabilitation component. Is there? Is that available? Dr. Ardeshir Hashmi 31:57 And I think it’s, it’s a composite, I think we’ve got to be very realistic and pragmatic about what is and is not possible. And I think that, you know, while there is in the research realm, certainly, you know, a lot of ability or ideas in terms of trying to stream together at the same time. I think in the current state, it is using the best that we have and trying to co-locate it. And by the co-location, I don’t just mean physical colocation, I mean, also on a virtual sort of platform. And so, because the sensory issues are so key, and we need to distinguish them from the cognitive issues, but also explore the links, right, so it’s both, it’s both. That is why something such as unified platform, and this partnership, you know, this, I would say even tripartite partnership between the individuals on this webinar, and all the folks who are tuning into it is so key, I mean, it’s integral, you take one part out, and you have a key piece missing, you know, could be the sensory piece could be the cognitive piece, and definitely, you’d never get to the link, if there is one. If any one of these pieces of the jigsaw puzzle is missing, Dr. Fred Ma 33:11 yeah, I will would add that, yeah. So definitely, it’s is kind of a circle there composed of all the components together in a circle and the missing one, this cannot you know, make a circle, for instance, you know, we have two products. One is Cognivue Clarity, which is, you know, 10 minutes medical grade testing device used by neurologic, neurologists, and other physicians to assist in the diagnosing of cognitive condition. And we have five minutes currently to Thrive, the consumer grade screening device, which was developed to enable, you know, automated cognitive assessment of patients outside primary care setting. When a cognitive assessment will benefit patients outcomes, such as a supplement to audiological and ocular evaluation. With that, you know, kind of a complementary to each other that, Thrive it’ll become a conjunctive tool for evaluating cognitive function. While this is not intended as a standalone diagnostic tool, but it will help, you know, audiologist to get a sense and refer to Dr. Hashmi from geriatric care or, you know, primary care standpoint to do extensive, you know, assessment for further diagnostic. Amyn Amlani 34:42 Yeah. And so as I’m listening to you both, and I wasn’t clear in my question, but it basically sounds like we all need to communicate together to make this model efficient. And if we’re missing a component, then it could potentially be negatively impactful for that patient. So that conversation needs to be widespread between the physician, the patient, and whoever else is within this, this journey that this patient is going to take. And so as we’re looking at cognitive screenings, and as we’re looking at all of the healthcare providers working together in order to move this thing forward, you know, are there opportunities, as you pointed out Dr. Ma, for other special, other, other aspects of the office to get involved. So for example, your devices here, do not necessarily need someone to administer them, because they’re self administering. So can we get a front office staff individual to start the process, which would then allow the clinician to do something else for clinical efficiency purposes, and then the the provider and the patient could connect again, and say, this is the outcome. And, again, sharing information, we need to share this information with your primary care physician, we need to refer you and so forth and so on. What are your thoughts on that? Dr. Fred Ma 36:05 Well, that’s a, that’s a big question, actually. And that’s an excellent question. And from Cognivue, I say exactly the same point, I wanted to have this device and that, you know, to be placed everywhere, because it can be placed in everywhere. And there, as long as there’s a healthcare, healthcare providing functions in that office, or clinics. Because of that data, people who are utilizing to get assessment or screening of the patients doesn’t need, you know, too comprehensive or medical license, you know, as long as you were trained, and to how to operate and then to, to coach people to use that machine. However, there’s another component about, about the reimbursement about practicing patterns, and then on and so forth. And then I just want to, I don’t want it to step on a turf, that practitioner who wanted to have a control of the assessment, or a screening of the patients to give up to the other people who are not a practitioner, or a healthcare provider to the oversight and losing the momentum of the, you know, the from ecosystem and of their return on investment in the meantime. So, of course, the amplifying the power of the device, to have all the benefits that the patient could receive, to assess their their cognitive function is the goal. So therefore, I turn to Dr. Hashmi to comment on that. What’s the best pattern? Do you think, you know, to maximize the benefits of our device? We’re not causing any setback of the the ecosystem for you know, the for reimbursement? Yeah. Yes. Great. Dr. Ardeshir Hashmi 38:14 Thank you for asking that. For my you know, my, my short answer would be, we need to really democratize the system. Right. And so there’s a status quo right now, which I’ll be very blunt even, is, to a large extent, self perpetuating, you know, why should it again, be the domain of a few? Is there a specialized knowledge? I mean, we live in a world where knowledge is at our fingertips, right. It’s only a one, search web search away. And so it shouldn’t be there. It is no longer the province of a few, nor should it be nor can it be right, it needs to answer that. So, so I think that, you know, the existing status quo it and we need to be together as jointly as a team, be very intentional disruptors of the status quo. And yes, there’s an ecosystem that is in place right now. Healthcare is in crisis because of that ecosystem. So if you’ve got an ecosystem that isn’t really, you know, fostering well being, then it needs to be actively disruptive, replaced, honestly, with, with a newer ecosystem in which everyone in that ecosystem is working in service for the patient and family working to top of license and is very honest about their own strengths and limitations. I mean, that’s absolutely okay. I mean, I would be the first to sort of admit that the reason that we’ve, we’ve been failing for the last 30 plus years is exactly because this is missing. There is a lot of lip service that I hear all the time about, yes, interdisciplinary teams, etc. But do I see a real interdisciplinary team? I haven’t seen that yet. I mean, the beginnings of it is sort of in the work that you’ve both been doing and I hope that we can, we can join you in that word. Dr. Fred Ma 40:04 And so yeah, so I just added to, you know, quickly and I, I totally agree this, this, you know, status quo need to be changed. And then there’s really, really related to how, and what. So I don’t know, if you remember our company’s mission, and then listed on the website, I really love this and always broadcasting that, you know, to the audience. And then number one is to ‘elevate the gold standard of cognitive health assessment’, that is really we are filling into status quo, but we reform that making this better. Second is ‘reduce the stigma of cognitive issues’. Okay. And finally, ’empower action with early detection’, this is our mission. So as long as we can fulfill our mission status quo will be renewed, and the new, you know, standard will be implemented, which is beneficial on both sides. Amyn Amlani 41:04 You know, as I listen to you both talk and if I was a clinician, I would want out right now and go get a product and start start implementing this because, you know, I feel it, I feel as though I’m now part of a team where, you know, as I, a lot of my my colleagues will have kind of felt like they’re on the sidelines, right. And so this conversation allows them to kind of view themselves as more, you know, part of the healthcare landscape as opposed to sitting on the sidelines. And in, you know, the organic conversation that’s taking place here, I hope, the viewers will see that. But one of the issues that we face as a profession, and again, we have to be honest and blunt here is cognitive, the cognitive component is not really part of our training as audiologist and so my question to you both, is, what advice would you give an audiologist about getting development and education in this area, so that they can become more vibrant players in this space in this ecosystem, to make things more efficient, and help our patients who really need this, this kind of information? Dr. Ardeshir Hashmi 42:14 Yeah, my, my own two cents on that would be, a lot of it is going to be a renewed self sort of belief, if you will, you know, when you have been deliberately, I would say, you know, sideline for a long time, I can only imagine how frustrating it must feel that look, I am, you know, the missing piece here of this patient’s, you know, solution here. And and I’m not sort of… I’m waiting for someone to give me permission to come in to the field of play. And I think that we have to give ourselves permission, right, and we have to partner with them. And my team always tells me well, you know, we should work with people who want to work with us. There are people who want to work together and disrupt that status quo and form a new team. It’s about, you know, that’s what you know, sort of This Week in Hearing is all about, I mean, your your webinar brings together people who do want to work together and can see a different future. And I think as long as those people are there, there’s a lot of hope for the future. So I think that belief should be there that yes, there may be a lot of people who are stuck in the past. But there are also a set of people who don’t like that past and want to move to something new, and they will be very willing to partner with you. The other thing is, it’s bi-directional. Right? And it’s incredibly feasible. None of this stuff is rocket science. There are people who are perpetuating this myth that it is rocket science, because if it is rocket science, and none of us can be trained in cognitive, you know, screenings and sort of assessments and interpretation, then we’re in real trouble. Right? And that is, in fact, not the case. Because the people who claim that this is their province or domain, they were trained as well. And so it’s our failure as educators, my failure, anyone else’s failure if we can’t pass on this knowledge, and share that, and when I say bidirectional, I mean, I know next to nothing about audiology do I want to know, of course, I get asked about this all the time from my patients. So I think as long as that mutual enrichment is there, that’s the only way that we’re going to move forward. So that would be sort of my advice. Dr. Ma would invite your your comment on it. Dr. Fred Ma 44:27 I totally agree. And I think the time, timing is good. The reason why I said the timing is good, you know, the, in the leading by John Hopkins, which is world famous a medical society in that they pointed out, “Hey, pay attention on audiology, pay attention on hearing loss”. You know long term hearing loss is really a disaster, it’s becoming number, number one modifiable risk – on top of hypertension, TBI, alcohol consumption and, you know, the obesity in your mid-life, that you know, so I think number one is awareness, awareness across the board because there’s only about 14,000 audiologists in nationwide, and it’s not very difficult to get everybody’s awareness. So second is, you know, once you’re aware – how are you going to do it? Because without, without connection to the mainstream medical practices, your awareness is kind of left out, right. So, like a Dr. Hashmi mentioned is has to be, you know, has to be, to be connected, how to be connected, and then the acceptance from medical, you know, societies and then also connected with medical society and from audiology is the key and the network together on how to make it a circle, and a you know, to make a loop and a circle, and then eventually, you will become a voice. So there’s modeling, and a voice, become a voice of a bigger, you know, that the bigger voice that does, you know, quality of life, patient care, patient first, it’s not you, not me, not MD, MD but patient. So therefore, you know, you know, we have to lower down those those numbers, there’s a 5.8 million diagnoses of Alzheimer’s today, and then estimated to over 10 million and you know, all together, you know, under diagnosis and then diagnosis. So in 2050, plus this pandemic influence. So how many is it going to be? So, you know, if we don’t do that now, you know, our healthcare system, we’re going to be collapsed later. Amyn Amlani 46:50 Yeah, well said, well said, and so, you know, to my, to my peers, it’s an open invitation to engage in this arena, you’re going to have to invest in yourselves, you have physician partners that are willing to welcome you onto the field. And I think it’s an exciting time. I think it’s an exciting opportunity. And it’s an evolution in the profession, you know, as we continue to grow from the 50 or 70 years that we’ve been around. And so I think it’s a, it’s a great place to be as audiologists. We’re almost at the end here. So any final thoughts? Gentlemen, before we conclude here, Dr. Fred Ma 47:28 I’ll say, I’ll say that I know, I haven’t mentioned we have, we have a large fourteen, you know, 13, 14, size of real world data collection, which is perspective designs, you know, following the routine practice of, of audiology clinics, that based on a pilot study of Dr. Jill Davis, in Austin, to engage, engage or implement on the dual track of Cognivue, cognitive assessment and the hearing, hearing, you know, assessment. And then while you’re caring for the hearing loss of patients, and you will follow up, whether there’s improvement of a cognitive function. So this will give us a, give us the benefits, awareness, and also the information built based on data, that data will be becoming evidence that’s showing and demonstrating, hey, the number one modifiable risk factor that we’re caring we are practicing is really true message whether or not you accept it is there. So is has to be has to be engaged it requires all the entire medical societies to work together, you know, that will be referral, that will be you know reverse, and for the patients that coming back and to adjustment, and then there are going to be and the one result, which is quality of life of patient improvement. Yeah. Dr. Ardeshir Hashmi 49:13 Well, my, my last thought would be, you know, the existing health system and the way that we are now in crisis is because health system has been tone deaf, and for Audiology colleagues will appreciate that too. What needs to be in place, and the only way that we’re going to find a voice for that, as Dr. Ma and Dr. Amlani both of you have said is to generate the research. There’s a lot that needs to be done. There is good work that has been done. But I think the call is there to join hands and do more of this work. So that we can put in the evidence which, you know, establishes beyond a shadow of a doubt that this is the way of the future. So appreciate the opportunity to discuss today. Amyn Amlani 49:55 Well, thank you, gentlemen. It’s been really enlightening. I, I always when we do these, I always learned something new. And I certainly learned a lot here. Hopefully, you know, a few months down the road or in 2022, we’ll have the opportunity to reengage have, you know, maybe this conversation and some additional ones and I really appreciate your time and your expertise. And, you know, my colleagues, I’m sure will will find this really, really enlightening and favorable as they start to evolve and take cognitive screenings as part of their clinical practice within their state licensure.