barbara weinstein audiology tuned

A Conversation with Dr. Barbara Weinstein: The Power of Subjective Outcome Measurements, Person-Centered Care, and a Multidisciplinary Approach to Hearing Healthcare

This week, host Kathleen Wallace sits down with Dr. Barbara Weinstein, Professor and Founding Executive Officer of the Health Sciences Doctoral Program at the CUNY Graduate Center.

Dr. Weinstein is probably best known for her role in the development of the Hearing Handicap Inventory for the Elderly (HHIE), a self-assessment tool containing 25 questions that are designed to assess the impact of hearing loss in the emotional and social-situational adjustments of elderly patients. In this episode, Dr. Weinstein discusses why using tools like the HHIE are so important in audiology, as well as the importance of collaborating with other health professionals as a key part of truly person-centered care.

Full episode transcript

Kathleen Wallace 0:10
Hello everyone and welcome to This Week in Hearing. I’m your host Kathleen Wallace audiologist, adjunct professor at CUNY Graduate Center and head of provider education at Tuned a virtual audiology platform. Today I’m pleased to be joined by Dr. Barbara Weinstein. Dr. Weinstein received her PhD from Columbia University where she began her academic career as a young faculty member, a professor and founding executive officer of the Health Sciences doctoral programs at the Graduate Center of CUNY. Dr. Weinstein also holds a position as an adjunct professor of medicine at NYU Langone Medical Center in New York City. The author of both editions of Geriatric audiology, Dr. Weinstein developed the world’s most widely used tools to identify patients with hearing loss which has been translated into 20 plus different languages and is used globally to document the negative health effects associated with age related hearing loss, as well as the outcomes associated with hearing aid use audiologic rehabilitation and counseling. Dr. Weinstein’s primary research interests include hearing loss, dementia and social isolation, physician patient communication, screening of age related hearing loss, person centered care delivery and the quantification of patient reported outcomes. Dr. Weinstein has long advocated for the integration of hearing healthcare into the mainstream via cultural, medical or religious institutions. Her research has profound implications at the intersection of audiology, Public Health and Society. She is proud to be selected as a 2022, distinguished alumnus for the Teacher’s College of Columbia University. Dr. Weinstein, thank you so much for for joining me today, as an alum of the grad center, I can attest to just how prolific your work is, and how much of an impact you’ve had on multiple generations of audiologists. So today’s conversation will definitely be an exercise in restraint for me. Because given that introduction, we have quite a few aspects that we could be talking about and do warrant further discussion. So we’ll just get right to it. But welcome.

Barbara Weinstein 2:25
Thank you for inviting me, I was honored that you reached out, I’ve been following your career. And I’ve been proud. It’s like being a parent. And when students, you know, take off and do their own things and initiate and are contributing to the field. It’s, it’s kind of like, feeling very good as instructed as a professor, which is one of the reasons why I have done this for so many decades.

Kathleen Wallace 2:52
I’m sure, I’m sure. And especially in New York City, you know, you probably have touched the career of almost every audiologist in New York City at this point. So the effect, the ripple effect of q&a is pretty powerful. And the ripple effect from Teachers College is really powerful. I don’t know, it’s a shame that that program even ever closed, because it does seem like the most prominent figures of audiology, at least in New York City came from that program. That’s true. So to start off, you know, mentioned in the intro that perhaps your your first claim to fame is the hearing handicap inventory for the elderly or adults. And that that really captures a subjective measurement of hearing difficulty in a way that hasn’t been done before, you know, at that point, and still remains perhaps the most widely used tool for audiologists. So what do you think the value is in having these sort of subjective measurements in addition to the objective measurements we’re getting from the traditional audiogram and, and other diagnostic tests?

Barbara Weinstein 3:55
Oh, what’s interesting is that a lot of people think that I did my dissertation in developing the hearing handicap inventory, but I didn’t, I did my dissertation on looking at hearing loss and social isolation in the elderly and loneliness in the elderly. And what I learned from that experience was from that research was that the pure tone audiogram is not predictive of whether or not somebody with hearing loss is going to experience feeling of isolation. They’re not It’s not predictive of their feelings of loneliness, no is word recognition, but the self report questionnaire that I use, which is the hearing measurement scale, was the most predictive of, of some of the psychosocial effects of hearing loss which we measure which I measured on my dissertation. And I and I realized then that it was important to develop a questionnaire that was focused on older adults, because even in those days, I, I knew that projections in terms of life expectancy and Hearing loss affects older adults most most profoundly. So that’s when, when I was When I joined the faculty at Columbia, I suggested to my mentor documentary How about developing a self report questionnaire? So basically, it was, I think, what I saw is that in those days, I recognize that the self fit the, the pure tone, audiogram only counts for a small proportion of the individual variability in the reaction to hearing loss. So there’s got to be other variables. And the self report seems to tap into a lot of different areas, which I, including auditory processing, so that’s so so in those that that’s when I, when I first started with the hearing handicap scale. And then what happens is, is I developed a long version, and I was interested in screening. And most audiologists were not really that interested in hearing screening. And I know that time is of essence Time is money for audiologists, even in the 1980s. So I said to dr. ventue said, I’m going to develop a screening tool for screening for hearing- hearing loss. And that screening tool ended up becoming widely used, and it’s still cited all the research that we did on the self report is still cited by the US Preventive Task Force. And most of the research on screening includes the hearing handicap. So the measurement, so the measurement of self reported handicap now we know it’s predictive of so many different things, which I didn’t know, of course, when I developed the questionnaire, and including quality of life, including mortality, including some studies dimension, including hospitalization, hearing aid uptake, of course, hearing aid benefits, so it’s really predictive of a lot of different areas in healthcare. Most audiologists still are not convinced of the value of the self report. But with Larry Humes create, publishing a lot of articles on auditory wellness, and measuring auditory wellness, using self report, and also now Brent Edwards is talking about the value of the self report, I think that we have the big guns in the field, the bigger guns in the men of field, the men in the field. And I think that that’s really helpful in terms of promoting the self report, because it really, I mean, it does capture what we need to capture to, to bring people into to our, to our clinics, and also with OTC, it’s got its OTC was interesting is because they’re the criterion for use of OTC over 18. But self reported mild to moderate hearing impairment, that’s an oxymoron because you can’t have a self reported mild to moderate hearing impairment. But all the articles that you’re reading now are dropping the self reported and putting in the mild to moderate hearing impairment. So there’s a lot of misinformation. And when I wrote and commented, I said, you know, you got to figure out how to self report. But that fell by the wayside. So it’s kind of thing. So self report is going to be important how you self report. That’s another story.

Kathleen Wallace 8:00
Yeah, and this is probably the most trusted way for us to measure that self reported aspect of it, which in a lot of ways, I think it’s a little polarizing audiology, as you mentioned. But for most audiologists, you know, of course, having some subjective measurement is crucial for proper care of a patient, you know, because in a lot of ways, it’s more important almost, and what you’re actually seeing which we see with the Hidden Hearing loss or auditory processing, we have to go with the with the subjective measurement.

Barbara Weinstein 8:30
So with the hidden, what’s interesting is that there’s now a movement afoot to have a metric for unifying the language in terms of how people understand severity of hearing loss. And there’s been Frank Lin and Nick Reed wrote an article about the value of a metric, they put their proponents of the four frequency periods on average. And then Humes and I wrote an article saying that by using the poor frequency periods on average is a metric you’re missing the people with hidden hearing loss 12% missing that people are processing. So that’s just a misnomer. So there there are definitely, there are definitely different camps out there.

Kathleen Wallace 9:06
Yeah, and I

Barbara Weinstein 9:07
I think there should be a combined I think there should be a combined measure, actually,

Kathleen Wallace 9:12
of pure

Barbara Weinstein 9:13
Pure tone and self-report

Kathleen Wallace 9:17
Yeah, and I know that Nick Reed and Frank Lin have been big proponents of having like a number to really quantify, you know, they want to have, you know, how we have the 20/20 vision standard, can we get to number for it? It seems like that’s a big, that’s something that people want, people want to understand their hearing better. So we do need to simplify. And I think part of the beauty of the hearing handicap inventory is that it makes it so relatable, you know, it’s it breaks it down and it makes it something where they really can think of very clear examples, and, you know, and assess whether it’s a yes or sometimes a no, and then all of a sudden they do have a score, where maybe their report they didn’t Have those prompts wouldn’t be as robust or accurate? You know, they might, they might say it happens all the time in the clinic where they say they don’t have a hearing issue, then you go through the HHIE, all of a sudden they’re coming up with, you know, a pretty big score. And then all of a sudden their answers start to change, like, oh, I guess I do have some hearing issues. So breaking down that barrier and relating to patients seems like one of the most powerful benefits of the measurement like the HHIE. Was that part of the antenna?

Barbara Weinstein 10:27
No, no, the part of the intent was just to measure how people were reacting to the hearing loss because audiologists in the past, were really not focused on the reaction to hearing loss. They were mostly focused on diagnostics. So audiology has gone through a lot of and I said this in a podcast that I was just on audiologists have gone through a host of different waves, certain areas, and topics are popular at different times. So for example, when I went to school for my master’s in the 70s, I didn’t have a class and immittance, but then so immittance became popular and when you went to conventions, the room was filled with all the people interested in learning about immittance, and then it came to when audiologists were allowed to sell hearing aids, then people audiologists became interested in hearing aids and that was the big thing in audiology. Then we had cochlear -not cochlear, but ABR became the technology that technology became the thing. And then newborn hearing screening. So we’ve gone through different stages and technology has always been at the forefront. And my my feeling was, is that we need to focus on the patient. That was, you know, that was been my focus in the 80s. And that’s continued with my focus, and only now is patient centered, people have been saying, Well, we have to really focus on what the patient says what the person says. And that’s throughout medicine through it. And we know in terms of self report, the self rated health is predictive of longevity, it’s predicted with so many things, as is self rated hearing difficulty.

Kathleen Wallace 11:58
Yeah, so person centered care, that’s even a fairly new term, right, that it’s putting a name to something that people, some people have been doing for a while, and it’s really sort of gained some steam. Ida Institute’s a big part of that, you know, there’s different influences there. So to you, what would a person centered care look like? What how do you think it’s best implemented by an audiologist?

Barbara Weinstein 12:20
Well, I think the you know, the first question when a patient comes into you is to ask about the journey. I mean, just to have the patient talk more about their experience. And if you begin to have an if you have an open ended question, you’re gonna learn a lot about everything you need to know about what’s, what’s the patient’s experiences, and based on that patient experience, that should be that should be the driver of how we, what we assess, and our recommendation. So the patient should be the driver, and then at the center, and decision making, it should the patient should be educated about the options about the findings about the options, and then patient should work with the audiologist to make the decision. But over and over again, I hear from so many of my friends who I sent to the audiologist, well, the doctor said I’m a candidate for hearing aids because I have a mild to moderate hearing loss, or the doctor said, I’m not a candidate for hearing aids. Because Because my hearing is not bad enough. And if we just keep going by the audiogram, rather than what the patient’s experience is, we’re losing out, which is why I think that’s the theoretically the beauty of the OTC is because it’s more self rated. But if it gets lost in mild to moderate hearing impairment, that patient centered care, I mean, the patient should be the one who’s driving the decision making once the audiologist educates, and that’s why in your when you were student, and now I still decision aids have been used in medicine. And by offering options to patients, we’re educating them, and we have to educate our consumers and and they’ll be driving decisions. So I just think it’s it’s a, it’s a partnership. And that’s what person centered care is. It’s not, you don’t look at the Audiogram and tell a patient okay, you need a hearing. And that’s just that’s just not, that’s just not the way we should be practicing audiology or medicine.

Kathleen Wallace 14:11
Yep, yeah. Where it’s really more almost like a flowchart of if this person says yes to this, you know, then you have these two options. And eventually you will get to perhaps a firm recommendation or at least be able to narrow it down. But I do think the best kind of audiology that could be delivered is almost more of a educator and consultant perspective of providing resources and then ultimately letting the patient choose from there. And as you said,

Barbara Weinstein 14:36
that’s going to be Yeah, and that will be the future. Now if we if audiologists embrace this whole OTC thing, we should be the resource and we should be the expert. We should be the go to for so many different things. But what’s interesting is that I don’t know what it’s I think that maybe this whole OTC movement will push audiologists to in a new direction. I hope I hope I hope In terms of being the resource person, yeah,

Kathleen Wallace 15:03
because I think we’ve, we know from people inside the field, we know that it’s not a black and white issue, it’s not hearing aids or nothing, we know that there’s a whole spectrum of options or solutions out there. And you’ve always been a big proponent for things as simple as a pocket talker or an app or, you know, all the way up to other assistive listening devices to a hearing aid, or a cochlear implant, you know, and having that full range is going to have to be crucial for for audiologist to be able to talk about it. And I think you’ve always been a very big proponent of that of having options and not necessarily viewing it as hearing aids or nothing. Would you say that you’re in embracer of technology, other than hearing aids?

Barbara Weinstein 15:48
Yeah. So that’s, I’m very, very concerned about the fact that not enough audiologists are referring patients for implicate who are just talking to their patients about all the options out there. So we should when we speak to our patients about the options, we should tell them about the smorgasbord of options from an OTC all the way to a cochlear implant, because people will be hopeful Well, if one thing is not working, and we can go to the next stage of technology and the next stage, and what’s disappointing, I have had refer I referred number of people for to cochlear implants for a cochlear implants and the spouse, the person who got the implant set, they each say independently, it’s life changing. It’s saved. It saved our relationship and saved our marriage. And why didnt my audiologist refer me for this? Because I’m the one who’s pushed them. And I think that I think we have a responsibility actually to screen for residual disability and to tell doctors, primary care doctors were talking about trying to get primary care doctors to do some screening. There’ll be a couple of articles coming out by Dubno on screening in primary care practices. But what we should be doing is be screening for residual disability as well, doctors should. So you have a hearing aid, how you doing with the hearing aid, is it working? And we need to measure with the hit self report questionnaire, for example, the hearing indicates how they’re doing even though they have the hearing aid even though they haven’t using accessories. What if you look at the research on cochlear implants, the average hearing handicap inventory score of people getting into implants is about 60 out of 100. So what is it? Why do people have to suffer that much and have that kind of severe disability before they end up finally, saying alright, enough is enough? I, you know, we just I think we have a real obligation. It’s very sad that audiologists are not making the referrals and educating doctors about hopefully, I’m playing fantasy, I think maybe, maybe helpful.

Kathleen Wallace 17:48
Yeah, and I think it’s a big part of building trust with the patient too, when you’re offering more than one option, if you just say, right, hearing aids, you know, the, if you if you give them a full range, I feel like that’s far more trustworthy, especially when you have a great range of, you know, level of complexity of price, you know, it’s it’s varied on a lot of perspectives from something as simple as an app to a surgery of cochlear implants. And that is really important for the patient trust. But what you said about the primary care physicians, that’s a good segue of a lot of your work has been very interdisciplinary, where you are working outside of the audiology bubble, with primary care providers, gerontologist lots of different specialties, because as you capture in the hearing, handicap inventory, there are all of these larger ramifications for hearing loss. And a lot of these other providers are the touch point for the patient. So can you talk a little bit about the research that you’re currently doing or, and and why you think that’s important for us to think outside of that audiology bubble and reach out to these professionals.

Barbara Weinstein 18:55
And what’s interesting is that just a blade within the past five years, a lot of audio- a lot of researchers are publishing in non audiology journals, and, and publishing about the effects of hearing loss in terms of in terms of all different health outcomes, um, in terms of cost of medical care, in terms of access to medical care. And I was fortunate enough that a colleague of mine, present colleague of mine, who, you know, just a couple of years ago was an MD and PhD, just reached out to me because she wanted to get involved in some research with hearing loss, and she has her own hearing loss. And basically, my dream was always to work with Docs, MDs, to educate MDs about hearing, hearing and the value of hearing because I think that that was the way for us to make our greatest impact. So we ended up now I’m ending up as part of a team at NYU, with geriatricians with public health, with statisticians with nurses practitioners with the whole team and we’re working on at this point we’ve done a lot. We’ve written a lot of articles on activation in terms of what what activates individuals to take action in terms of in terms of health and hearing, hospital readmissions, and what’s present, the doctors were really interested in reaching people when they enter the healthcare system. So we’ve been doing a study funded by the Veterans Administration, the pilot was at the Manhattan VA looking at screening people for hearing disabilities using the self report, giving them a personal amplifier, and then seeing if the ability to hear the doctors hear better understand better in in, in emergency rooms, affects outcomes reduces the number of rehab hospital readmissions, and looking at preferences in terms of hearing it using hearing aid versus the personal amplifier. So that study, we’ve published that study and we did show that the using this personal amplifier among veterans who get the best hearing aids, they’re finding them of this personal amp was a great value, especially in emergency room, which is so noisy, and we’ve now we’ve now expanded the study to five more Haas VA hospitals throughout the country. So that’s really good. So the -an entry point for screening for hearing loss. Hearing difficulties might be an emergency, or branches. You remember my colleague who Josh shoulder, he’s head of Geriatrics at NYU, he so he’s interestingly, his father was an ENT doctor. So So interestingly, he’s interested in yours. And of course, he’s a geriatrician, and he’s head of the dementia clinic. And he’s now requiring every single patients clinic, get a hearing, hearing test, and self report. We also we also social isolation, loneliness is another one of my passions. And it wasn’t people were not interested when I published that article and social isolation and loneliness. But now obviously, it’s a it’s, it’s big. We did a little bit of study in a in a independent living facility, with people who are socially isolated. And we screened a hearing and pure tones and self report. And then we did give them personally and find to see if that helped them get more engaged. And that was the pace that they became more engaged. So and then that the the activation studies another public health because my colleague, Dan Bluestein, is a public health person, in addition to MD she was interested in patient activation, what motivates people to take action for their health open to hearing health. And what we did find was that older adults with hearing difficulties are less activated, they don’t they don’t take ownership. They don’t go go in and we have to work to activate our patients to educate the patients. And we know that this is an issue with people with have don’t have the means that people have who are low health literacy, which is another area of mine, we have to really educate these people, because these people are definitely falling for the cracks. And, you know, perhaps the OTC will reach that population, but I’m not so sure it’s gonna, because of the lack of health literacy and lack of understanding about hearing. So trying to educate the public about hearing difficulty. I think we did you do that project with the PSA, you did that project? PSA? Yeah, that was great. That was a great project. And, you know, educating people about, about the public health aspects of here of hearing is is, is really, really important. And our professional organizations have not yet cracked that nut. So that’s what we’re doing. And publishing in the medical journals has been really tough. I actually will say that COVID And the, you know, the issue of masking the masking of the face has made people realize how, how frustrating it can be to not understand people. And but the problem is, I mean, I’ve this weekend, a couple of people I’ve ran into the they’re not wearing the hearing so white wearing a hearing aid, it’s such a pain in the neck, most of the mask like people use my hearing aids. So this is this is a real real issue. It’s a real, it’s real interesting, but it’s raised. It’s raised awareness about and sensitivity about hearing difficulty.

Kathleen Wallace 24:22
Yeah, I think that the functioning outside of the audiology bubble, it does seem like you are moving the needle far more than all of our internal research within audiology that we are publishing just in our audiology bubble. And, you know, what comes to mind is the recent Cleveland Clinic study about the low hearing healthcare literacy of physicians or nurse practitioners and PAs, have you come across that like is is hearing loss on these people’s radars when you are presenting these studies or what’s the reception been for Are the people outside of the audiology bubble? We’ve known things for a while, is it new information to everybody else?

Barbara Weinstein 25:06
I’ll give you an example of a colleague, friend and a colleague, who’s a psychiatrist. And about eight years ago, I was really excited it was coming up, I was coming up with a grant for screening for hearing loss for doctors for screening in primary care, and referring for hearing aids or other technologies. And I said, I’m really excited, can I share my idea about how you can screen how you could refer? And he said to me, as a psychiatrist, he said to me, Barbara, this is about eight years ago, why would I screen somebody for hearing loss if hearing aids don’t work? And I was like, wow, that’s kind of interesting. And that’s when I got a couple of my students, maybe in your cohort to do to do study surveys of physicians, in terms of what they know about hearing loss and what they know about hearing aids and, and Fast forward four years ago, he said to me, Barbara, I’ve heard that there’s a link between hearing loss and dementia. Can you tell me a little bit about that? And can you tell me a little bit about what hearing aids what role hearing aids my play in that regard? And I told him, and he read the literature, and I shared the literature with him. And he’s a hearing aid user now. And and he’s certainly it’s made a difference in his life. So and then I have another friend who, who was on the cusp, he had a self so significant hearing handicaps and self report, his hearing loss was was on the borderline. He’s a he’s an attorney. And he said, Barbara, what do you think I should do and I shared the literature about hearing aids and hearing aid use and the the moving of the temporal lobe to the occipital if you if you don’t use your and sensory deprivation, the value of hearing aids, so he too, got, he too, got hearing aids. So I just think that the more people understand that the earlier people are identified in terms of hearing loss, like the Lancet suggests, midlife identification, because earlier earlier adoption, even a personal amplify, that’s gonna lead to earlier adoption, that can make a difference. And, and I think that’s really kind of, but we have but the stigma still, there’s still this stigma with hearing loss and hearing aids. And I think that one of the reasons, one of the problems with with one of the contributors to the stigma is that manufacturers keep making the hearing aids smaller and smaller, and less and less visible, making it more and more difficult for people who need the hearing aids to use them. If you can see that somebody’s got a hearing loss, you’re gonna modify your behavior, if it becomes more acceptable, acceptable, made with the OTC we got, like people, you know, people walk around with these, these air pods in the ear. I mean, you know, so nobody cares how they look.

Kathleen Wallace 28:02
So what do you think an audiologist role is in OTC? There’s still a lot unknown about, you know what exactly these OTCs will look like. There’s a lot of promise for how effective they could be, you know, if they have if it’s used appropriately if they’re given enough resources. If audiologists frankly buy into the concept, what do you think an audiologist? What do you think the role of an audiologist is as we shift to OTC or even healthcare professionals at large since you do interact with a lot of other specialists.

Barbara Weinstein 28:36
So I’ve been a proponent of OTC and I’ve, and I’ve advocated and I’ve written articles, in non refereed journals about the value of making more or less affordable devices, more more affordable devices available. I don’t think that, I do not think that the OTC is going to make hearing aids more affordable. And, and I think that was so that’s just an affordability is an issue. And hearing aid prices are not going to come down because audiologists continue to say and will continue to say it’s not the price of the hearing aid that’s costly. It’s the service. So it’s really, really important for audiologists to start unbundling and if people get used to an audiologist un bundle and charge for their services for their education, for the value added of speaking working with an audiologist, that that can be important. So we should be the go to professional for advice and we should charge for our services and we should be helping people live with hearing loss rather than use hearing aids. And I think most audiologists spend more time with the technology. And then by the time they finished with the technology. The patient doesn’t want to come back anymore because I mean you go back three or four times and they’re tired of going back patient to somebody, I’ll just Oh feel patients, they like me basically like to come back. You haven’t even gotten to the patient living with the hearing loss because you don’t have time. And you’re not. And, and they’re just we have the audiologist has to focus on the patient, and the tech, not the technology and with OTC, this is a chance, you know, people are gonna buy this the OTC and then they’re gonna realize, well, you know, it’s more than just the technology. And also if you’re not tech savvy than me, the audiologist so there’s, and maybe they’re going to be so many choices, it’s going to be hard for people to really understand, especially for older adults or certain older adults. Age, it’s going to be difficult and I still contend it’s going to they’re going to need the the advice of an audiologist, but audiologist should not be considered hearing aid salespeople. So I think you were at the I think you were at the HLA meeting when we spoke to the HLAA group and yep, and I did a survey of that group. And and the question was, “if you had, if you wanted advice or counseling about how to live with hearing, hearing loss, how to communicate with people with hearing loss about the feelings and the effects of hearing loss, who would you go to?” and the HLA people said, I wouldn’t go to an audiologist all you do you’re a hearing aid salesperson, you don’t know anything about how to live with hearing loss. That’s just, I mean, that’s our future.

Kathleen Wallace 31:19
That’s been a long standing issue for Audiology of separating the professional from the product, you know, they’ve become synonymous when they’re, they’re not, and it does go back to the person centered care. And it also goes back to how your research, you know, part of why it is so prolific and valuable to audiology, is because it is. And I say this in a very flattering way. It’s it’s practical information, you know, it’s information that would, that actually is going to be digestible and understandable by people outside of the audiology bubble. You know, people can understand social isolation and loneliness and quality of life, you know, they can understand these, these these concepts that are affecting overall well being and the role of hearing healthcare in that, where it seems like sometimes in audiology, we saw as we sort of lose the forest for the trees, and we get so technical nitty gritty, that OTC could be this real opportunity to separate those two again, and focus on that person centered care. Is there anything that you would be changing with your if you’re with the HHIE today, or, or audiology, after curriculum,

Barbara Weinstein 32:35
curriculum, I would change the curriculum. And how’s that, for example, I think that teaching about hearing aids in one class, and then cochlear implants in another class, and then children in another class, I mean, the entry here or rehab in another class, it all should be, it’s all part of the same package. I mean, and here and there, the hear piece. So that’s why you learn all about hearing aids and you don’t connect it to cochlear implants, because they’re not there. They’re not It’s not taught together, and it should be should be taught together. So I just didn’t should have, like pediatric geriatric and then all the other end the areas connected, and that’s how I would, I would present audiology. And I think also we need to get outside of I think we need more classes in counseling. And we need we need people to feel more competent counseling and knowing how to work with patients. Now this work the studies out of Australia in terms of the amount of time patients spent talking versus the pace the audiologist spent talking. It’s It’s absurd, but audiologists are just, they don’t feel comfortable, not talking and not. They don’t feel comfortable when talking about the patient feelings. So I think the future of audiology is in is in rehab in counseling and in communication strategies. And I think that it’s interesting, I was just I just did a podcast about dementia and hearing loss. So that was my second after the by social isolation study my hearing handicap inventory, I did a study on hearing loss dementia, one of the first study on dementia hearing loss. And he interestingly said that he thinks that cognition and measuring cognition screening for cognition, and somehow working it into the evaluation is going to be the future for for Audiology, which is kind of interesting. But I think and I think that that is true. If audiologists understand better the impacts of cognitive issues on hearing but even if you have normal hearing on processing so I think I’m there’s there’s there’s a lot week out and then balance of course and tinnitus. I mean the all these different areas. This is these are the things nobody else is doing it. And we should be, we should be owning it. When students come in to start in, come in and they’re applying for Audiology, they say I want to, a lot of them want to come in because they want they see cochlear implants, and they want to really make a difference in people’s lives. When students graduate, what they say is that I want to work with hearing aids, they come in wanting to work with they will come in wanting to work with the person they leave wanting to work with the technology. There’s something wrong with that.

Kathleen Wallace 35:25
Yeah, yeah. And yeah, something’s happening during the four years. And I think a big part of it is the the modeling of, you know, being very mindful of what environments you’re exposing the students too, and making sure that there are audiologists that are, you know, setting a good example, and to your point about potentially expanding more into, you know, brain health and dementia, only if audiologists are well trained and qualified to do so. Because obviously, that’s a very slippery slope. And I think people should be cautious of that. But it does seem like there needs to be more emphasis on critical critical thinking perhaps is the easiest way to put it of connecting those dots. As you said, you know, we’re viewing things in vacuums. And we’re not thinking that a hearing aid person candidate could quickly shift into a cochlear implant candidate or, you know, shift into even an overlying auditory processing, you know, these things happen together. In conjunction, there is never just one thing at a time. And as far as the clinical practice of audiology, what what do you think the, you mentioned, a focus more on some of the specialties and what audiologist can do that nobody else can do? Why do you think so few audiologist actually offer these services? You know, tinnitus, for example, auditory processing disorders, oral rehabilitation, sometimes it can be hard to find even in a major city like New York City. Why do you think that is?

Barbara Weinstein 36:56
Well, I think that you know, why hearing why the OTC Act was passed because of accessibility and affordability. And I think it’s the same thing with affordability with hearing aids is affordable, and not going into other areas, it’s because they can’t afford to, because they’re not going to make the money that they want to make. So why wouldn’t audiologist have in their practice? Well, the different accessories, I tried to start a business with some people with some people in terms of selling hearing aids, hearing assistive technology. And it was very, it was very difficult. We couldn’t do it, but and some audiologists don’t carry this assistive technology. Like why wouldn’t, why don’t you carry this? And why do they don’t because it’s not they can’t make enough money on it. And but you can make money if you charge, psychiatrists can charge $500 And people are going to pay out of pocket. So if we have the expertise – physical therapy, physical, physical therapist, people go to physical therapist, people go to occupational therapists, they’re going to pay for this because it does make a difference in their lives. audiologists have to believe in their value, in my opinion, if they started measuring the value added their value by measuring outcomes after patient comes in and following patients and say every year come in for your hearing check. It’s you know, there could be a change, we have to reach out we have to bring patients in, but audiologist so I was I consulted on audiology practice and said send out a hearing handicap inventory every year the patient Hello, talk to them how you doing. And if you score this comment and we’ll talk maybe we may have to make adjustments. But then the issue is well, then I have to charge for that visit and they’re not used to paying. So the patients are not used to paying because everything is bundled and the audiologist is uncomfortable charging. And that has to change if we’re going to I think if we’re going to survive as a profession, this unbundling is really, really is really, really important. And the telehealth I think, I think telehealth is really, really important. I think telehealth is great in terms of reaching out making sure that people are using the technology correctly seeing how they’re doing. So for example, I think I might have told you this I was once part of the grant where we educated it was a grant to teach older adults how to use technology. This was 20 years ago. And because none of them used hearing aids, none that use computers. So we we got money, we sent students into the home, we got the computers into the home, we had the students and go into the home and teach them how to use the computers. And then I taught two courses to these lay people on hearing loss and hearing aids and was fascinating. And so this was before zoom. And it was fascinating because these people I knew the audiogram said have you said everybody’s got to have the hearing test and who’s being part of the study. And and they would show me their hearing aid and they would show me how they were operating it and then I would show that I would be able to communicate with them, you know, over over the over the computer and I think that there’s a real place for telehealth, but I don’t think in terms of programming hearing aid I don’t think that’s where it’s at. I think it’s more on this face to face and helping people communicate better how to, knowing what the problems are helping them put in. So I think there’s there’s a role for it. But in terms of in terms of remote programming, you’re going to need somebody to help it that’s going to be just, that I think you need to come to the audiologist.

Kathleen Wallace 40:19
But yeah, I do think it has a lot of potential with the counseling and patient education aspect, which is a giant niche that needs to be filled in audiology. You know, we’re in the age of Dr. Google. Everyone’s googling everything. Yeah. And people want to do their research, people want to be informed consumers, which is why the decision aids are so powerful. That’s why being separate from the device is so crucial for Audiology. It really it there’s so much information that people want to know. And it is interesting that audiologists it seems like we have a major PR issue where, you know, we feel like we can’t charge for our time sometimes because it’s not perceived value to other people. Why isn’t that perceived value because we’re not effectively communicating our value to to the world. Outside of the audiology bubble, again, your will

Barbara Weinstein 41:12
in terms of Sorry to interrupt it, outside the audiology bubble, I think that it’s really, really critical that we when when a patient is referred to us, and we have to write a report to a doctor, for example, the report talks very to hearing loss immittance, this, the most important thing is patient got hearing aids patients hearing aids patient is using the hearing aid in many situations, patients is no longer feeling the their auditory wellness has improved. And they’re no they’re more engaged with individuals. And we recommend that they continue to engage because the hearing aid is making. We need to communicate that to primary care doctors, and geriatricians because patients only go in and complain, Oh, my hearing aids not working. But they don’t they don’t talk about when, when and how well they’re doing what a difference it’s making. And I think we need to be the ones to advocate for that. In our report in our reports, I mean, then that’s because doctors are going to doctors are going to read that read that. I also think we have to make sure to I think we have to also counsel patients, and this could be something that they should pay for how to advocate for themselves. So doctors are not going to modify their behavior, we need to train our patients to advocate for themselves, in terms of when they have their medical appointments. And when they go into hospital when they they’re admitted to a hospital, don’t leave your hearing aid behind bring you hearing it but this is what you do. So there’s so many roles that we that we can play in terms of education and living, living with hearing loss.

Kathleen Wallace 42:42
Yeah, and you’ve mentioned HLAA a bit ago, and going to an HLAA meeting really should be mandatory for audiologists to really get a glimpse into what people with hearing loss are saying and thinking and, and honestly what they view audiologist says, because I think traditionally, where at least lately, a lot of that burden of educating people on how to live with hearing loss has been coming from other people with hearing loss, which is great. There’s absolutely no replacement for that firsthand experience. But it should be in conjunction with audiologists, and at least it seems like from HLAA involvement that I’ve had, that that is not the perception that people with hearing loss hat. We’re not that trusted professional or ally to them as much as we should be.

Barbara Weinstein 43:31
Well, the and the HLAA people were very strong advocates for this OTC. And there were very, very outspoken because they’re really and their website is amazing in terms of all the educational material. So that’s so that’s a resource and audiologists should be referring people to the HLAA website to the HLAA meetings local national, because they really are very educational and you can pay some but most audiologists don’t really have much experience. Well, that makes experience they don’t really understand exactly necessarily how what it’s like to live with a hearing hearing loss unless they hear from hearing the bad person which is why Sheri Eberts I think came for you there. So Sheri is now on the, she wrote this amazing book, which I’m buying, which hopefully purchasing for every single student in the program because it’s that important for them to read from the perspective of Gael and Sheri. But we don’t we don’t. audiologists are really not listening enough to the patient and really understanding what it’s like. And to even though you’re working with patients with hearing loss all the time. I don’t know just getting it from the viewpoint of the perspective of hearing impaired person support. That’s why the assignment went up my foot went by. I was the one who said we should have counseling first semester, not to talk about audiology counseling just talking about counts in general. The first assignment is for students to interview hear people with hearing loss so that they can understand what it’s like to have hearing loss and then ask Patients, if they know people with hearing loss if they know the name of their audiologist, and they don’t. So why don’t why don’t people every single time I see somebody with a hearing aid, I say, who’s your audiologist because I may know them. And nobody remembers their audiologists name. It’s really upsetting. But you know, your doctor’s name.

Kathleen Wallace 45:18
So there’s a lot of work to do.

Barbara Weinstein 45:20
I think so. So that’s why I’ll stick I’m gonna, I’m gonna stick with it. I mean, when I do my, when I go speak to different meetings, and I think that people think she’s still around, she’s still alive. I’m gonna continue to be be around and be an advocate for hearing loss, hopefully, for a long time to the future.

Kathleen Wallace 45:40
And on that note, just a few closing thoughts. Where do you think the future of audiology is? You know, there seems to be some traps and some potential. What do you have given your career? What do you advise or foresee as the most promising future path for Audiology?

Barbara Weinstein 46:03
I mean, I think we really have to be trusted members of healthcare teams. And I think that that’s really, really important, I mean, orthopedist, would not do anything without referring the patient to a physical therapist. And we should I mean, if you go to, if you have these different medical conditions diabeetus heart disease, dementia falls, the audiologist could be, could be such an important person in the lives of these people. So I think that we really have to become more integral parts of healthcare to trusted members of healthcare teams. Right now, most audiologists working in hospitals, for example, they’re in part of the ante, do they and they don’t even and they’re so busy with the end patients, that they never even they don’t even have to reach out to other services, because they’re, they’re so busy, we need to we meet to be reached out. And we need to be more integral to the healthcare team, because and I think I personally think that every single patient who is admitted to a hospital, there should be some sort of record about hearing status and a note on the chart, difficulty communicating. And I think there should be universal precaution, universal communication. Signs, just like there are universal infection control, and that so I think circles communication in hospital settings is really, really important. So I think communicate hearing, and communication needs to be more linked, because most people most doctors don’t know that hearing is central to communication. And we did we did do a study on that. And we found that the studies on communication, very rarely mentioned hearing, which is which is um, so we have to, we have to be part of the healthcare team, people have to understand that hearing communication are critical. And hearing is critical, critical to well being and people who are, who are being treated for many medical conditions.

Kathleen Wallace 48:01
I think that’s a lot to work with. That’s a lot to work with.

We have a future could be right

Yes. Yeah. And I think that’s the biggest thing with audiology is it there are plenty of opportunities, if we’re going in the right direction. If we fight the right battles, you know, if we keep trying to harp on the same things, then yes, we’re going to be digging ourselves in the hole potentially, but broader horizons, we there are plenty of things to do with audiology, which I think is a very important message right now, certainly from someone that has had such an illustrious career in audiology is involved in the education of audiologists, and has one of the biggest name recognitions outside of audiology, which is so important to have a good spokesperson for Audiology, outside of Audiology for healthcare at large.

Barbara Weinstein 48:47
Just one note, no note about that. Unless … So my daughter who’s like she’s 30 now and she was like 20. He says, I met my boyfriend’s husband parents, and they said, Well, what do you do? And what does your mother do? And she said to me said, I really don’t know what you do, mom, I know you’re famous. I know you speak. I just don’t even know what you do. It’s very, very funny.

Kathleen Wallace 49:09
That sounds like a typical, you know, child reaction where I feel like you’re a little too close to the sun. You don’t know what’s going on. But everybody else does everybody else in audio. Well, thank you so much for having for being on the podcast today and having me interview you. I really do appreciate it and everyone listening out there. I encourage you to take these words and run with it. And we really do need to do our part of thinking outside of that audiology bubble and making sure that we are promoting the profession and our expertise effectively to other healthcare professionals and working with them for the sake of our patients. So thank you very much, Dr. Weinstein. It was my pleasure to have you

Barbara Weinstein 49:50
Thank you. This was really wonderful. Thank you so much. And good luck. And hopefully I’ll see you I’m sure I’ll see you soon. Thank you so much. Take care

This special episode is sponsored by Tuned. To learn more about Tuned and to register as a provider, visit

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About the Panel

Dr. Barbara E. Weinstein received her Ph.D. from Columbia University where she began her academic career as a young faculty member.  A Professor and Founding Executive Officer of the Health Sciences Doctoral Programs at the CUNY Graduate Center, Dr. Weinstein also holds a position as an Adjunct Professor of Medicine at NYU Langone Medical Center in New York City.  The author of both editions of Geriatric Audiology, Dr. Weinstein developed the world’s most widely used tools to identify patients with hearing loss, which has been translated into 20+ different languages. Her primary research interests include hearing loss, dementia and social isolation, physician-patient communication, screening of age related hearing loss, person –centered care delivery, and quantification of patient reported outcomes. Dr. Weinstein has long advocated for the integration of hearing health care into the mainstream and her research has profound implications at the intersection of audiology, public health, and society. She is proud to be selected as a 2022 distinguished alumnus award from Teacher’s College of Columbia University. 

Kathleen Wallace, Au.D. received her undergraduate degree (B.A. in Music) from Dartmouth College and Doctor of Audiology (Au.D.) from the CUNY Graduate Center. She is the Head of Provider Education at Tuned, a virtual audiology platform, where she oversees the continuing education branch called Tuniversity. Kathleen also runs her own practice as a hearing and communication consultant and content creator, with a focus on patient education and the promotion of the expertise of audiologists. In addition, Kathleen is an adjunct professor in the Doctor of Audiology program at her alma mater, the CUNY Graduate Center.






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