Audiology Beyond Hearing: Opportunities in Assessment of Cognitive, Balance and Vestibular Function

Dave Kemp 0:10
All right, and welcome to another episode of This Week in Hearing. I’m your host Dave Kemp, and today we are joined by Dr. Richard Gans and Tom O’Neill. So why don’t we go one by one allow you to to introduce yourselves. We’ll start with you, Richard.

Richard Gans 0:26
Well, thanks, David. Thanks for coordinating this program. I’m Richard Gans. I’ve a PhD in auditory vestibular physiology from The Ohio State. I’ve been a past president of the American Academy of Audiology, and I’ve been involved in audiology, otolaryngology neurology organizations and societies for over 35 years. I’m the founder of the American Institute of Balance. We’re based here in Tampa Bay, but we basically operate, license or manage clinics in 32 states around the United States, in India and the United Kingdom.

Dave Kemp 1:10
Fantastic. Great to have you here,. Richard. Tom, how about you?

Tom O’Neill 1:14
Yeah, thank you, David. I too, appreciate you taking the time to coordinate this and put this together. So my name is Tom O’Neill. I’ve been in healthcare for over 30 years, but in a number of different spaces. So I started off in consumer packaged goods moved to pharmaceuticals, been in vision care, also in surgical equipment, capital equipment, molecular diagnostics and life sciences. Over those 30 years, with companies like Johnson and Johnson, Bausch & Lamb, Hologic and Kyjun, I’ve been here at Cognivue for the last four years, building out this business. We are, we are the only FDA cleared or excuse me, the first FDA-cleared technology of computerized testing of cognition. And we do business both in the US and in Canada. And we’re based here in in Victor New York, which is right outside of Rochester.

Dave Kemp 2:10
Fantastic. So the reason I wanted to have these two on today, you know, I think where we stand today in the field of audiology, there’s a lot of uncertainty and a lot of disruption. And I think that, as I’ve gotten to really know your two companies, and get a feel for the direction that you’re sort of trying to kind of take the industry in your own way. I feel strongly personally that you two are really helping to kind of guide the industry toward a path of viability and sustainability. And so I think for this conversation, we’ll really talk through the importance of the vestibular aspect of audiology, as well as the opportunity that cognitive screening really presents for the profession. So, Richard, I know that you have you know, you founded the American Institute of Balance 30 years ago, and you’ve obviously been in this industry, you’ve done a number of different things from owning clinics to serving as the president of AAA. So can you speak a little bit about the American Institute of Balance and your time there and then ultimately, how things are shaping up with the Centers of Specialty Care that that you’re now placing all around the country?

Richard Gans 3:26
Well, great, happy happy to do that. So you know, for most of my career, I’ve been publishing textbook chapters, research articles, we’re the largest educator in the world of audiologists, physical therapists, occupational therapists, physicians, in the vestibular sciences. So we train about 1200 to 1300 professionals every year. We also for many years, have owned and operated our own neuro-diagnostic clinics here in the Tampa Bay area. So just in our own clinics, we see over 800 patients a month. This is vestibular-balance patients. These are not essentially hearing aid or traditional audiology type patients. We we have a referral base just locally, of over 2000 physicians, PCPs and specialists. About three years ago, a number of our friends in audiology, ENT, said rich what we appreciate the science, but teach us the business. Right? So, right? As my grandmother would say “from this, you make a living?” right. So the idea is, well, you’ve taught us the science, but we don’t understand really the business of this. I mean, should we just buy equipment? Who should we hire? I, you know, I took an ENG class 20 years ago, I don’t know what to do. So using some very good friends in ENT, neurology, audiology, we rolled out a A to Z program called our Centers of Specialty Care. Right now we have 68 practice owners in 32 states operating about 100 clinics. This is in addition to our, I guess 10 or 12, corporate facilities that we do joint ventures with usually hospitals, large multi specialty groups. And I’ve got to say in just 36 months, our folks are very, very happy because we won’t let anybody fail. We have our strategic relationships are with all the vendors, suppliers, great people like Tom’s team at Cognivue. And we’ll talk about the role of cognition in all of Audiology. Not just balance, but hearing. So we’re excited we we believe that this year, we’ll probably add another 100 to 200 clinics. We do these through an exclusive licensing agreement. And in several locales, the licenses have already been taken up. So what we do is we want to do well by doing good, right, so the bottom line is you’ve got to help patients. So a Center of Specialty Care and AIBs hallmark is going into a community and opening our arms to ENTs, Neurologists, primary care physicians, gerontologists, internists, people treating diabetics, patients with dementia, neuro muscular, neurodegenerative conditions. So we are serving the entire population in a community, children and adults who have any type of equilibrium disturbance. Now, having said that, audiologists have a unique opportunity not to be a competitor with a physician, but rather to be a resource for the physician. And so when you understand that physicians are not our adversaries, they’re our friends, our colleagues. That’s how you build your practice. So we have the largest practice in the world of its kind. We don’t advertise directly to the public. We don’t need to, right. So just like a radiology lab, a blood lab, the referring physicians know who the experts are in the community. Now, why cognition? Well, one of the big things we focus on is fall risk management. Now, in a recent article in the Journal of Otolaryngology Head Neck Surgery,

they just tracked over 805,000 patients complaining of dizziness, vertigo, imbalance, and they tracked where these people went.

They went to emergency departments in hospitals, or they went to Physician Clinics and offices. Guess what the authors conclude? Looking at meta-analysis, that’s big data. 805,000. Tom, I’m gonna send you this article, just came out. I’m just referencing it now in a new article we’re doing, guess what they found. They’re not well served. It’s not cost effective. It’s inefficient, because people don’t know where to go or who the right person is to go for help. And even if you think you’re going to the right person, they may not have the bandwidth to do any of the testing or assessment that’s necessary. Now, most of these patients have comorbidities diabetes, hypertension, cardiovascular disease, peripheral neuropathy, many many different things. Okay. Fall risk has been shown to have greater incidence in one group in particular – people with untreated, undiagnosed hearing loss. Agrawal’s study from Hopkins showed that – strike one. Strike one, untreated sensorineural hearing loss. Strike two – even mild cognitive impairment. We’re not talking about what to the point you get to dementia, or Alzheimer’s, because at that point, you’re probably under significant care. You might even be institutionalized, whatever the case may be. So we’ve known that executive function, vestibular, visual spatial reaction time, all of these conditions disrupt a patient from paying attention to their environment. Because when you ambulate when you walk and move, you’re talking to somebody you’re looking at something. Well guess what, if your cognitive function is even minimally off, you’re gonna have a problem. So what we were impressed with with Cognivue, is you’ve got all these different domains. It’s not just a one trick pony. Oh, yeah, you’ve got cognitive decline, do sit down, you shouldn’t be walking, just lay down there. And we’ll get to, you. No, our research that is going to be published over the next two weeks. We’re very excited about this. Our research shows that there are in particular, three domains that Cognivue screens for that now we’re showing a strong call correlation with fall risk in individuals with absolutely normal, pristine, peripheral vestibular function. So our a priori expectation is this rotary chair, ocular them, see them, he caught all of these tests can come back normal, and you can still have a patient with a fall risk. And that fall risk can be identified by a five minute screening, right, let’s say with Cognivue, and that can change the course of someone’s life. And whether they fall fracture a hip, a femur, wrist mTBI so now you have a mild cognitive impairment. That is an undiagnosed, untreated. ‘Oh, yeah, Mom, you know what? Everybody gets like that’ mom goes out. After going to Piggly Wiggly she can’t remember where a car is. So we took an orange tennis ball, and we put it number one cars had antennas, can’t even, right. So you have to… Mom has to get a part time job for Domino’s. So we put a Domino’s thing on mom’s car. But these are important things. Right. So now we have as audiologists, a two pronged attack. We understand, right, the implications of untreated, undiagnosed hearing loss, right? Social isolation, depression, everything that goes with that, of course, you’re going to have cognitive decline if you’re not interacting with people, we’ve seen that with COVID haven’t we? Increased social isolation and depression. But now we can also say, You know what, okay, mom’s a little depressed, we’ll get her a little Elavil or something will boost her up. But let me tell you something. If mom falls and has an mTBI, and can no longer age in place, because she can’t remember her cats are, she can’t remember if she took her medicine. She can’t remember if she shut the oven off. She can’t remember if she said this security alarm at night used and we got a problem. So what we’re trying to do as clinical scientists, is look at every tool that’s available to allow audiologists and other practitioners help their patients age in place, stay healthy, stay well, and also save Medicare and third party insurers untold billions in unnecessary emergency room visits.

Dave Kemp 14:31
Yeah, I mean, I couldn’t agree more with all of that. I think it’s so fascinating that this whole, everything that you laid out there like for me as somebody that’s just in this industry, I’m not an audiologist, I look at this and I say, what’s the argument against this? You know, what, this again, when when there’s so much fear and doom and gloom of there are all of these threats that are presenting themselves to these professionals. I never hear anybody talking about competitors that are in this space. I mean, this is how you build inroads within the medical community, like you said, at the top there, Richard, you know, it brings to mind the conversations that I’ve had before with Jill Davis, who I know is a, you know, a huge proponent of Cognivue is, you know, she’s built a gigantic referral network of physicians now, where she has patients actively coming through her doors, because she’s built those relationships. So, Tom, in your eyes, I mean, as you’ve kind of worked through this a little bit, where do you see the role of cognitive screening, fitting into the day to day of the audiologist?

Tom O’Neill 15:41
Yeah, no, first of all, I think Richard did. Dr. Gans did an amazing job and was very eloquent in explaining it from from start to finish, I’ll give you just my perspective. To add to that is a three or four years ago, we actually took a step back because we’d focused solely on the physicians, the MDs, the primary care docs, the neurologists, the psychiatrists, and we realized they that in the primary care role, they just necessarily didn’t necessarily have the time to be able to have these conversations or do this cognitive testing of those patients. So we, we took a step back and we we wanted to look at how we could broaden the screening class. And so we launched Cognivue Thrive, which is our five minute screening. And, and we wanted to go talk to optometrists, audiologists and retail pharmacists and we found a really strong partner community within that audiology-ENT sector and channel in and because as Richard said, it is the most modifiable risk factor before mild cognitive impairment leads to something more permanent, like dementias up to an including Alzheimer’s disease. And so I took a step back, and we took a step back at the organization. And we said, Alright, how do we bring value? Because ultimately, it’s always going to be about the patient. Right? So how do we bring value to that patient? And and I’ve heard the number referenced many times that it takes about seven years for a patient to finally, from the start of their hearing loss to actually seek some hearing intervention. So for me, it was about bringing value clinic great clinical value to these audiologists and ENTs. In a way that allowed them to have a bigger clinical conversation with their patients. So it’s one thing to say your hearing is x, you have a hearing deficit of x, it’s another to say you have a hearing deficit of x in and by the way, that that could be impacting your cognitive function, let us show you how that could be happening, and be able to have a bigger broader conversation with a patient about their overall health, not just their hearing health, right. And then with with Richard and what he what he said again, so eloquently was that additional tie to vestibular. So if we can bring value to these clinicians, as they’re having these conversations with the patient, patient, I think it it hopefully helps patients seek some type of intervention sooner, whether it’s vestibular intervention, whether it’s hearing intervention, allow them or give those patients, you know, a reason to seek some intervention sooner and quicker, because we know that the outcomes will be better. So we do have a belief that the earlier testing drives the earlier intervention, which drives to better outcomes. And, and ultimately, that’s, that’s, again, what’s going to be really, really important for those patients. So that’s how we think about it, within Cognivue and being able to partner with somebody like Dr. Gans, and his institution, the American Institute of Balance is a huge value to us to bring that message I was, as I mentioned, in the beginning, I was in optometry and I was in optometry at a time where I would say there were a lot of similar things, things going on. We had 1-800 contacts you had, you know, discount deep discount retailers, you had stuff, contact lenses starting to be sold on the web, all this stuff going on and it felt like this huge threat to independent optometry, when in reality, it helped grow the overall market but but separate from that. What happened with independent optometry which I think is what you’re going to see in independent audiology is they started going after and looking at other technologies like retinal imaging, right so retinal imaging is now something that you have that happens every single day in and optometrists office. But before David before that whole onslaught of the laws changing, federal laws changing and 1 800 contacts, the optemestrist was always the front of the eye. And the ophthalmologist was the back of the eye. What the, by changing the laws and forcing the optometrists to actually start to think about their patient and their business different, they actually started to expand their services. I think that’s what you’re going to see here in audiology as well, whether it’s with vestibular, or whether it’s with cognitive, mild cognitive impairment and cognitive testing, I think you’re going to see those audiologists look to differentiate themselves from the online, or the deep discount retailers in ways that that they can’t be served there, ultimately, for the benefit of the patient.

Dave Kemp 20:38
Yeah, I couldn’t agree more there. And I’m actually just kind of to the side looking at a picture I took at the last presentation that I saw Jill present on, you know, the importance of cognitive screenings and in the opportunity for audiologists, and what this really brings to mind here, and I’ll, Richard, you’re nodding your head, along with what a lot of time is saying, you know, she had this whole slide around a implementing a more holistic patient evaluation. And she sort of had an iceberg illustration, and at the tip of the iceberg is the peripheral auditory system. And then down below is the central auditory system. And and it’s sort of like what you said there with the front of the eyeball on the back of the eyeball is the opportunity, it seems, is really, I think, you know, for these, if you really do want to stand apart from all of these online, you know, to be analogous to what you just described their time, these online, avenues of distribution or big box retailers, all that is to look at what’s actually happening below the surface and have a much more comprehensive patient evaluation.

Tom O’Neill 21:43
Yeah, I think, and Richard could speak to this better than I can. But there’s been a dialogue within audiology and ENT between the ear brain connection for years now right in, I think that’s, that’s going to be the foundation of the clinical reason and the validation of why it makes sense. Richard just mentioned that it’s vestibular connection in the science, around that connection to cognition, you’ll continue to see work by Cognivue, AIB and others, to continue to bring clinical validation to, to the market to audiologists, because that’s what’s really going to give us that staying power, and going to help us make a difference again, not only in the clinicians, businesses, but in the patient’s lives.

Richard Gans 22:33
And what we’ve got to do, Dave, you know, I kiddingly, say, I’m the Moses of audiology, right? I got everybody put down the stones, enough with the pyramids – come with me. Right. But now for 40 years are walking around the desert going, how do we get out of here! We’re not building pyramids anymore, but you still don’t get out of the desert. It’s because of their belief lids, their belief lids. Let me give you some examples. You look at the scope of practice, AAA. and ASHA, I wrote a lot of the scope of practice for AAA, I’m a reviewer, the scope of practice for ASHA. It’s ginormous! It the what’s in your scope of practice is ginormous. Most audiologists probably don’t even access 50% of what their scope of practice says they can do. And most state licensure, which is what you practice with, pretty much follows whatever ASHA or AAA says. So nobody is, as I say, nobody’s blocking your shots. So this is all about a belief lid, of some, well, I don’t know if I should do that. I don’t know. I’m…what’s somebody gonna think if I do that? But that’s ridiculous. Stop asking everyone else what you should do. Right? And go look at your scope of practice sets. And your scope of practice will show you that. That by not practicing to the widest expanse of your practice, you are – what you’re doing is you’re keeping yourself really in the same position as all your competitors. You are not going to outdo any of the major hearing aid companies who have, who own dispensing outlets. You can’t. They’re paying a fraction of the of the product cost. Likewise, in 2006, I co-authored a local, what’s called a local coverage determination. It’s now enacted in 28 states. Do you know, in 28 states – only, only an audiologist or an ENT or neurologist can be paid by Medicare for doing vestibular testing? You’re welcome. We basically excluded everyone else. We excluded all possible competitors, except the three key folks in 28 states and you still haven’t done it. Can you imagine if you went to 28 states and said only an audiologist could dispense a hearing aid? What would you do? You’d go berserk? You think it was Christmas in March? Right?

Tom O’Neill 25:51
So Dr. Gans, I think, so Dave, one of the things – so I agree with everything Dr. Gans just said, I also want to be clear and that we’re not asking audiologists or ENTs to be neurologists or psychiatrists or even primary care docs with regards to cognitive assessments. There they, our screening is that – it’s a screening, it’s not a diagnostic tool. If they’re we’re looking for audiologists and to Richards point, audiologists and ENTs to do what’s in their scope of practice, and to have intervention that they have all the ability and capability to do. If that patient presents with more than that, then absolutely, like Dr. Davis said, refer them to their primary care to their neurologist to their psychiatrist to that that specialist that’s going to be able to take care of a more significant issue that may have progressed beyond hearing or vestibular. Right. So I think we’re, again, it’s working hand in hand. And to Richard’s point, to Dr. Gans’ point. It’s working within the scope that you’re available, that that’s available to you

Richard Gans 26:58
right now. Absolutely. You know, how often you go to you to an internist or primary care doc, maybe you’re over 40. You know, I’m not there yet. But right, and as part of your your physical you get an EKG, right, that’s like standard now – you go into a GP get an EKG? Right? The PCP she doesn’t run in and say, Wait a minute, I get to take you to a Cath Lab, I’m gonna get a run, scope up your femoral artery. What does she say? You know, I don’t like the way this looks. Let’s you know what, let’s get you over to a cardiologist. I’d like them to take a closer look at this. But it’s the internist or the PCP that starts the patient journey.

Tom O’Neill 27:47
Right.

Richard Gans 27:48
Right. And that’s what we’re talking about here. The patient journey, the audiologist has a unique opportunity. But because of the the nature of the reimbursement from hearing aids, at least historically, it’s well, why should I look over there? I’m doing just fine. Until you’re not. And I would urge my, my audiology brethren, to look at balance and cognition and tinnitus. And in you know, every aspect of the profession because otherwise a one trick pony practice, you’re going to be the next Brontosaurus. You’re going to be it’s not a question of if – It’s a question of when. You have to embrace all these technology tools. And the overall well being of your of your patients. And this will, this will add years to your practice. It will add value to your practice. Right? It’ll add to your bottom line. All of these tools, right? The big boxes are not going to do… I don’t know. You know, what, are they going to try to have a medical type of practice? I doubt it. So why are you waiting? What? How long? You know, it’s like on the Titanic – the ship is sinking, let me go put on my tuxedo.

Dave Kemp 29:28
Well, and it definitely brings to mind to on this very program. Dr. Amyn Amlani. He interviewed. I don’t know if he’s now your chief or your former chief medical officer, Tom. I think it was Fred Ma or Frank Ma. And yeah, Dr. Ma and and the other gentleman from the Cleveland Clinic and that was yes. Dr. Ardeshir Z. Hashmi. And that was the huge aha moment I said I saw was they basically said that we view – these aren’t audiologists – and they’re saying we view audiologist as being the front line of defense for screening for cognition that seems to be one of the most suitable professions out there to run these types of screens. And so, you know, what more validation do you need than to have these really high, high up, you know, MD’s stating that, that to me was was just amazing validation.

Tom O’Neill 30:22
Well, again, it’s further validation that the steps we took three years ago to to broaden the screening class, beyond the primary care neurologist, psychiatrist to include audiologists, optometrists, retail pharmacist, guys, I want to be clear this issue of mild cognitive impairment leading to more permanent things like dementia and Alzheimer’s, this is not going to be just a healthcare issue. This is a society issue. And it’s one that you know, there, and we’re living some of this through COVID. Once something gets designated, right, as a pandemic, like COVID, did, doors open up, resources are available all those things, to be very clear, that is exactly what’s happening. With the 10s of our hundreds of millions of people around the world, when it’s not MCI mild cognitive impairment is not captured early enough. And those things that are modifiable risk factors aren’t managed, it becomes more more permanent to dementia, that is a pandemic, that is, again, not a healthcare issue alone, it is a society issue that we’re all going to have to deal with. So broadening that screening class, is absolutely essential to us, you know, having a bigger impact sooner in a patient’s life.

Richard Gans 31:40
And also audiologists have to understand this is not 1970 anymore. I mean, there are a lot of our colleagues who are practicing like we’re still in the 70s. For example, patient comes in, you know, what, if I’m sitting at the dining room table, and there’s the family’s there, I, you know, it just sounds like a lot of noise. My wife and I stopped going out to our favorite restaurant because it was overwhelming. I it was embarrassing. I couldn’t, you know, like, at all, you know, the I said to the waiter, you know, you know, why would I want you to eat my role? And he said, No, would you like me to heat your roll? Right, right. So it’s all of a sudden now, it’s, I don’t want to go to the movies. I don’t want to play majong I don’t want to go to the club. I’m just gonna stay home and read my book. Right. But audiologists have to realize when a patient comes in and says, What is the number one complaint? I have trouble hearing in noise. I have trouble hearing, Oh, I hear you fine. I can hear if there’s three or four people, just all the things we just talked about. And then you do nothing but give them NU6 or W22s at increased threshold in quiet. No wonder the patient says I don’t need a hearing aid. They heard you perfectly. You’re talking in their ear without any noise at 30 to 40 decibels above their threshold. Of course they hear great, right? You’ve got to use a QuickSIN, you’ve got to use speech in noise as and then look at that with a Cognivue. We don’t hear with our ears, we hear with our brain. We don’t see with our eyes, right we see with our brain, the eye is nothing more than a lens. The ear is nothing more than a mechanical and a neurochemical transducer. So if you’re going to really look at solving someone’s communication needs, yes. Let’s look at the mechanical. Let’s look at the electro chemical. Are the outer hair cells working? Are the inner hair cells working? Ah, guess what they are and the person can hear in noise. Yep. Well, unless you’ve done a cognitive screening. How do you manage this patient?

Tom O’Neill 34:23
Yeah, Richard, I think you’ll agree I hear. You know, those those folks in the industry like Dr. Doug Beck, talk about the difference between hearing and listening. So we hear with our ears, we listen and interpret those sounds with our brains. And they have much he and folks like him and Dave Fabry. They all have more elegant ways to explain it. But but that’s really what you’re talking about is, is how do we make that distinction? How do we make that connection for the patient? And I think that’s where Cognivue comes into play.

Richard Gans 34:57
Absolutely. If you think that the ear stops at the Cochlea that’s nonsense

Dave Kemp 35:06
Yeah, I couldn’t agree more. So I think, um, you know, with this whole line of thought to, Richard, you had mentioned that there’s a paper that you’ve written. And, you know, right before we started recording, Tom, you said that Richard basically proved the link that, you know, between cognition and vestibular. So I want to give you to an opportunity. I mean, I think that we’ve really honed in on the importance of these two separately, but and we did discuss this a little bit at the top. But can you shed a little bit more light on this as to what this how these two interrelate and how you think about the relationship?

Richard Gans 35:46
Yeah, so number one, I’m very fortunate that I have a massive amount of highly sophisticated equipment. We actually own more NeuroCom computerized dynamic posturography than any facility in the world. We have six, we have I think, 10 or 12, Rotary chairs, we do cervical vemp, ocular vemp, electro cochleography, evoked potentials. So what we wanted to do was look at this, we put our older adult patients aged 65 and older, through the NeuroCom EquiTest. Now the sensory organization test is a very interactive test, if anybody has ever seen this, the patient is standing on a platform, the platform is moving there, their visual surround is moving. And this test has been shown over its over 35 years to have among the highest sensitivity of indication of postural instability. Remember, this was developed in the 80s to evaluate the balance function of returning astronauts on the space shuttles. So it’s the gold standard. We then also put these patients through every single test. rotary chair, oVemp, cVemp, every test that exists, what you would expect and we they ran on the Thrive five minutes screener on Cognivue. Now, what you would anticipate is that if they were abnormal, on the CDP, they should be abnormal on one or more of all those vestibular tests. But guess what? There’s a segment of the population that was pristine, on all the vestibular testing, but they were reduced on three domains of Cognivue. And in fact, those individuals that were lower on Cognivue had more than a 13 time likelihood of having elevated fall risk. So this has amazing implications, because most people are not going to have one CDP let alone six. They’re not going to have all this. What this means is this. audiologist ENTs, neurologist, nursing homes, elder community centers in five minutes, without necessarily having the advanced technology can at least begin to say you know, based on the science, this is a high risk faller. And then we can intervene, whether it’s behaviorally right in their home, making sure they can age in place, right. We can have somebody whether it’s an adult child, visiting nurse, go in, make sure the bathroom is full proof, the kitchen, all these kinds of situations, if they’ve got other kind of comorbidities, right, that we find out, they’re an uncontrolled diabetic. The other thing is if you look at the comorbidities, the vast majority of Americans are going to live their older years with chronic debilitating medical conditions. 60,000 new cases of parkinson every year, Parkinson people are not dying. Look at Michael J. Fox. The lifespan of people with Parkinson’s is out now almost a normal lifespan patients with multiple sclerosis because of the special cocktails that neurologists have put together, people are living normal lifespans with Look at type two diabetes, cardiovascular disease, peripheral neuropathy. So our patients are not just coming in with this little suitcase. Oh, yeah, it’s kind of a mild cognitive impairment. They’ve got all these different things. But the cognitive impairment makes them even more complicated to manage. Because if I put a walker in every room in your house, but you don’t remember to use it, it doesn’t do us any good.

Tom O’Neill 40:33
Yeah, to put a bow on that, David, and this is the thing I’d say too, because because I can’t add much more than what Dr. Gans just outlined. Other than this is specifically my point around the more clinical data, the more clinical validation, we can put behind our, our technology within the aud and ENT space, in addition to speech path, and, and neuro and Psych and in senior care facilities and other stuff, the better off that patient’s going to be.

Dave Kemp 41:03
So as we come to a close here, I think this has just been such an insightful conversation. Where can people learn more about your two companies? You know, if this is something that they’re interested in learning more about, I mean, some people this might be the first time they’re being really exposed to one or both of your, you know, Richard, with you in the American Institute of Balance, or Tom, with you and Cognivue. Where would you recommend they go to inquire more about all this? Yeah.

Tom O’Neill 41:34
So first off, they go to our website, and they can ask or request more information, www.cognivue.com. We just expanded our sales force. So there’s a high likelihood we have a local rep in your market. The other two things I’d say is, we’ll be at the major conferences, right alongside with Richard and his team at AAA and others, ASHA as well. So we’ll, we’ll be at those conferences. And so you can come in and learn more about what we do. And the last place is our partnership with with Dr. Gans in the AIB. So AIB is certainly very well known, and a leader within the industry. And so you can certainly go to AIB and learn more

about Cognivue as well.

Richard Gans 42:20
Yeah, and for us, if you come to dizzy.com, dizzy.com, we have a huge website. If you’re interested in just taking educational workshops or online courses, you can do that. I also free open access, you can go to dizzy.com. And look at the Dr. Gans blogs, you can walk view, almost 50 blogs of me working with children and adults with balance dysfunction. If you go into our research and publications, you can access probably 70 or 80, textbook chapters, articles that we’ve written over the years, if you’re interested in becoming a center of specialty care, when you go to the homepage, there, you’ll see that you can just click on it. And we’d love to have an opportunity to visit with you. If you know if anybody just wants to talk about why we use a cognitive screener. I you know, we have 33 We have a team of 33 people here at AIB we’d be we’d love to have a conversation with you and share with you our experiences and why we believe cognitive screening is an integral part of modern audiology practice.

Dave Kemp 43:41
When did you buy the dizzy.com URL? That was pretty good forsight

Richard Gans 43:47
before you were born? No, we know I’m not kidding. So

Dave Kemp 43:52
probably ’89

Richard Gans 43:53
we operate and you know, a lot of my training was with NASA and Air Force. And in the mid 90s. We actually with Army Air Force exchange services. We ran two model audiology clinics, both at MacDill Air Force Base, the home of Central Command and special ops here in Tampa and up at Eglin Air Force Base in the Panhandle there Pensacola and so we were working with Army and Air Force personnel. And I saw this on their card. It was like email. So you know that you may not remember the old joke that Al Gore in trouble. ‘Oh, I invented the internet’. Remember that story? Yeah, well, he didn’t invent it, but it was actually his project. Right. So the whole thing about the internet was it was a communication system for the military to be able to speak to each other. If traditional, you know, telecommunications went down. So I Never forget Mary Hallmark. She was a captain, based on Fort Collins. She says, Yeah, you should look into this this thing. It’s called the, the worldwide net or something. So it’s like 94-95. So I go online, and I bought it for $5. And I thought to myself, well, if I lose five bucks, who cares? But I could have had Nike, Coca Cola, General Motors, everybody just thought it was a goofy, a goofy thing. So we have dizzy.com. With dizzy.org, we actually probably own about 20 or 30 URLs. Because I’ve learned over the year, I just collect a whole set. And so I just keep collecting them. And you know, maybe I’ll use them or whatever. It’s not exactly crypto. But

Dave Kemp 45:54
you were you were kind of like in the same vein. It was like crypto of its time back in the 90s. Yeah. So anyway, this has just been an awesome conversation. I really appreciate you to coming on. Lots and lots to think about. And I’m looking forward to seeing how everything continues to progress with you, too. So thanks to you, too. And thanks for everybody who tuned in here. Thank you the next time.

Richard Gans 46:15
Thank you, Tom, to you and your team for all the great help and support you’ve done for our centers all around the country. I know they’re very, very appreciative to have access to this great technology.

Tom O’Neill 46:30
That goes both ways Dr. Gans. We appreciate you and your team. We got great things ahead of us. For sure. And and David, thank you for including us. We appreciate the time.

Dave Kemp 46:40
Absolutely. All right. Cheers you too. And thanks, everybody. Buh bye.

Richard Gans 46:43
Take care. Bye bye.