ADA AuDacity 2024 Featured Keynote: Innovation Update in Hearing Care

Thank you. Before we get the panel going properly, I’d like to introduce my two panelists – Steve Taddei. He’s the lab director of Hear Advisor, but he also has an interesting, broader background. Tell people a few words about yourself. Sure. Well, hello, everyone. Well, I’m happy to be here. My background actually started in audio engineering and music, and that naturally led into the hearing sciences. And being a clinician, I worked for around five years in a nonprofit treating kind of a range of hearing losses, working a little bit with like, ces evaluations through the va. Since then, I have kind of left clinic and gone a little bit more into the educational role, and I teach at various colleges and topics of, like, audio production anatomy and physiology, psychoacoustics. I absolutely love doing that. And then, as Andy mentioned, I also am the lab director at a newer company called Hear Advisor. And our goal is to objectively evaluate hearing aids, both prescription, over the counter advanced earbuds. Even now, musicians earplugs or concert earplugs to help pull back the curtain a little bit and help consumers find the technologies that they need. Thanks, Steve and Dave Kemp, many of you probably know, as the director of business development for Oaktree Products and so much more. So tell us more. Well, thank you, Andy. Its great to be here. See so many friendly and familiar faces out there. So my name is David Kemp. I’m the director of business development at Oaktree Products. Oaktree was a it’s a family business that was started by my parents back in 1992 out of the basement of our home. And I joined the family business full time in 2016 after working there as a child, breaking child labor laws as a kid. And when I joined my degree in college was journalism. And I was trying to think of, how can I apply this thing to this small family business? And one of the passions that I had was sort of on the emerging technology that was happening in this industry back in 2015, 2016. And so I started my blog, FuturEar. And that then kind of morphed into a podcast. And over the last few years, I’ve had the opportunity to really kind of talk with a lot of different professionals from around the industry, from the audiologists to the industry professionals in the various companies just. To kind of get a sense of, you know, where the technology is heading and how the industry as a whole is kind of adapting to a lot of these different changes. And that’s how I got to know these two guys was through all that work. So that’s how the three of us kind of got here today. And you forgot to mention one thing. You also, along with Kevin Liebe, started the This Week in Hearing a podcast which later on became my pleasure to be one of the co hosts of, and I’ve known both of these gentlemen for a long time. I can’t think of two better people to talk about innovation in all aspects of hearing care. So I want to start with you, Steve, and ask you AI is what’s in everybody’s mind. And of course, that’s more of a colloquial expression for a suite of different technologies, which we’re now seeing implemented both in devices and in hearing care and diagnostics. So, I want to ask you, you think about what’s coming to diagnostics and testing, how we’re getting to the point where you could automate the full testing suite. You could, for example, after you set somebody up with the physical equipment, you can do an audiogram, you could do an ACT test, you could run a real ear measurement, have the computer running at all, integrate those results, and then generate a pretty good first fitting with all of that data incorporated. Do you see that as a threat for audiologists or as an opportunity? Well first, simply, I definitely see it as an opportunity. I think any industry, if it is ever unwilling to kind of adapt or grow or learn, it will be to the detriment of it. But with all the technology that we have nowadays, I think it can always be used as a tool to either speed up clinic times, increase the accuracy of our fittings. When we were discussing about, coming here and talking about topics like this, I looked a little bit into some of the research of AutoREM, for example, and it still doesn’t seem like it’s quite there. There was an evaluation by, I think it was Gus Mueller and Todd Ricketts in past few years, 2018, I think. And this was through audiology online. So it wasn’t like a published research article. But they did take a look at, for the major manufacturers and their various forms of autoREM, and they found that it was close in certain situations, potentially at lower volumes, like 55 decibels inputs and 75 decibels inputs, there was a little bit more fit variation. And I think one of the summaries of their talk in these 20 questions was, it can be a useful tool. You have to be careful, though, because it might not be very accurate, because many of these systems, they don’t allow you to measure, like real ear unaided gain, for example, which can create various abnormalities in the fitting. And what they ended up doing to keep this long story going is they double checked the autoREM with typical speech mapping. And again, sometimes it was close, sometimes it was far. A little bit far off. So I do think it can definitely be a benefit to us. I think there still needs to be some work with that form of like autoREM, at least in this specific example. But for my understanding of clinic, and I got out of clinic a long time ago because it definitely was rewarding, but it wasn’t my truest passion. But clinicians, I know they’re always struggling to find this balance between them wanting to provide the best possible care for their patients, and then the administrative side of billing, having to see as many patients as possible for billable hours. So I think this could, in time, be a very useful tool to help improve patient outcomes while also respecting and validating the time of the providers who are trying to do that. Okay, thanks. And Dave, there probably aren’t that many people who’ve talked to more audiologists over time than you through your business. Kind of take the pulse of how people are feeling about automation in the clinical setting and how people are feeling about it today. Well, I mean, I think that, you know, it’s inevitable that you’re just going to get you know, technology will continue to march on and that there’s going to just be this like steady march of more capability, you know, more or less that these things can do. But I think that there, there’s a broader conversation to be had here about sort of what’s happening, I think, for the profession and how all these macro forces right now are, I think, changing the entire landscape for the provider in terms of the amount of competition there is now for providing treatment. So all the different avenues of access you can go to as a patient you have the continued vertical integration of the manufacturers. Its just getting harder and harder for, I think, the small business of today to compete in that old sort of legacy structure. And so I think that when you sort of look at, well, what’s kind of the opportunity here I think that there are you know, types of technologies that people can leverage to help to level the playing field a little bit. I mean, I think about, you know, some of the different entrepreneurs that I’ve met you know, over the last few years that are doing all kinds of new business models that I think have been enabled just recently with some of the. … Yeah, we had the power down. Yeah, it must have been that good. Okay, well yeah, well, where I was going with that is I think that, you know automated diagnostics is kind of the least of the concern in terms of is this a. Threat for the provider of today. They got a lot of other fish to fry. And in fact, I think that these might lend themselves to be opportunities. And I know that would segue into some other things that we want to talk about, but I view these as ways that the provider can ultimately extend themselves, because you’re going to ultimately need somebody to interpret all of this and help tell the story of what’s going on. I mean, I think the thing that differentiates going and seeing a professional is the professional guiding you as to what is going on with you. And I think that that’s the value of this whole thing. It’s not necessarily the test. It’s helping people to understand what the test is telling them. Well, and yeah, you mentioned that thinking about the shortage of audiologists not only in North America, but worldwide, really. But we’ll keep it to North American context here. If you look at a map, you can see there are many rural counties without hearing care professionals. And so people have to drive a long way. It can be difficult. You also have people who have other issues, and it’s difficult for them to travel. So how do you take that need reaching more people with hearing care when there’s a shortage of audiologists? How do you take advantage of the tools that are available today to do that? And Steve, I’ll start with you and then Dave. And that’s a great question, and I think it’s one that we definitely are working to figure out. I think Covid was a little bit of a catalyst on how we can still offer viable services without maybe the same verificative measures that we have. But what I will say is, over the past few years, I’ve seen a large growth in, I think, just online platforms that provide very useful and unbiased information to pretty much anyone, providers, as well as individuals with hearing loss. And one that comes to mind is tunedcare.com. and I know you’re both familiar with them. Danny Aronson Heather Malyuk, Laura Sonnet. And in my mind, it’s this new wave of audiology for audiology. And there’s a disconnect then, from a desirable disconnect, I think, from just technologies. Patients can still schedule appointments with specific providers that specialize in areas important to them, such as tinnitus, maybe music, audiology balance and see that provider, patient relationship grow through online video conferences. Technology is also a part of their platform, but they always describe themselves as being brand agnostic so that it’s not like they sell specific hearing aids because they get kickbacks on them or affiliate links or anything like that. And they also do a lot of in house vetting of those products. So I think that’s just one example of how a team can come together and grow a community of online audiology that is still profitable for them as providers, where their salary is not based on a sale of a device or linked to it and the consumer. The individual with hearing loss also gets wonderful service from the comforts of their home. Okay. And Dave I mean, you’ve seen all kinds of innovative platforms developed by audiologists for reaching people in various ways, whether it’s mobile, whether it’s by telecare, share some best practices that you’ve seen reaching people in underserved areas. Yeah, I mean, I think to Steve’s point, you know, you’ve got some really interesting new ways that I think the audiologist is making themselves more accessible to the masses using technology. And I think, you know, I was telling Dr. Victor Bray earlier that I was looking back at a past conversation that he and I had about the workforce data analysis that he and Doctor Amlani had put together. And, you know, the reality is, is that from 1999 to, I think it was like 2022, the workforce has been primarily flat. It’s about 15,000-ish audiologists. And you have that happening now. The workforce hasn’t really grown and you now have the true bellwether of the silver tsunami coming through. And so it’s truly more demand than I think, ever before for audiological services and basically the same amount of supply. And so I think that it’s just really interesting to kind of now see, you know, as I was alluding to earlier, is like the entrepreneurial landscape. I think it is kind of market dynamics where the supply and the demand are having to be met through new ways. And I think that, you know, I’m calling to mind a different panel that I did where I had four different audiologists that were all sort of starting their own businesses. So I had Kathleen Wallace I had Randy Smiley, Amanda Levy and Melanie Hecker. And the four of them described their different businesses. And ultimately, the common denominator across all four was that they noticed a gap in the market in terms of there isn’t somebody that’s doing, doing this specific service, whether it’s telehealth or it’s APD, or it’s in person visits in a big metro or it was helping maybe some different underserved populations. And they talked about how these business models sprung up to ultimately meet those needs. And I just kept thinking throughout that whole panel of, along with the common denominator being sort of this ability to kind of use technology and use some of these new methods to provide more access to your services I think that a lot of this is being enabled to buy different technological changes in innovation that are fueling a lot of this stuff and ultimately empowering what I kind of perceive to be the next generation of what a private practice looks like. And again, it’s not to say that the sort of notion of what a private practice and what we’ve had for the last few decades would cease to exist or anything like that, but I just think that you have new business models that are springing up to cater to all this demand in ways that some of these, I would say more vertically integrated, top down, larger entities aren’t as concerned about because their prerogatives are different. So in some ways, it’s kind of, it’s disadvantaged you as an entrepreneur, as a small business person, but in other ways, I think it’s dramatically empowered you and provided you with some really exciting opportunities. So for me, that’s how I kind of see things right now is we’re in a really interesting period where it feels like the table is being reset in some ways. Okay? And so I’m thinking about Steve, because Steve lives in a kind of a small to medium city within a rural part of Illinois. If you leave Rockford, where he lives, and go all around, it’s really rural. And so you take thinking about what Dave said and what’s available in terms of whether it’s AI based or straightforward, how equipment is getting smaller and easier to use, and you have remote tools like put your clinical hat back on and take me, say, five years from now, you’re going to service that rural population all around you. How do you do it? No pressure. So this was an issue that would come up in clinic because it was a rural area, it was a nonprofit that I was working for. And we would tend to see people who would struggle, for example, to even drive a few miles to get to a hearing aid fitting appointment. And we would regularly think, like, how can we create some form of mobile audiology where we would go to their facility or their house or if they’re at a like, extended living facility to provide those services? And I know that model already exists, but I don’t think it integrates quite well. With traditional clinics. It’s more of like, you have a mobile van that you’ll go every few months and you’ll help these facilities. So I think this is where having a team of people, not just audiologists, instrument dispensers other health medical professionals who can help provide some of these services using either remote care with remote programming, for example. Or I know hearX has a new form of like, video remote otoscope that can still be used for remote diagnosis. Something that comes to mind is, and I think Dave, this was something that you had mentioned in the previous. Discussion we had that in Alberta, Canada, there were there’s a clinic or a hospital that was in need of more ABRs because they didn’t have an audiologist there who could perform it in house, and they found an audiologist semi locally. Not that they had to come in, but they were able to still provide that diagnostic service from the comfort of their home, I guess you could say, or their clinic by using teleconferencing video software, and then them gaining access to that computer just through remote controls. And this is something that Zoom will give you for free, actually. You can control someone else’s computer so long as they give you access to do so. So I guess in five minutes, if I were to try and create a business model for this question, I would try and get a team of people with different levels of expertise, use as much as possible these various forms of speedy clinical care, such as, like remote video otoscopes for a diagnostic, even using AutoREM, it’s something that can be done remotely. And I would just try and stagger it as much as possible where each person is working efficiently within their specialty bubbles. So hopefully then you could still see a broader range of people from more rural areas that don’t have the same transportation capabilities as perhaps the average. person, which is interesting because the World Health Organization, in trying to deliver hearing care globally, and there are countries that don’t even have audiologists, for example, or might have one or two in a capital city, what they’re trying to do is arm local health clinicians. And so it sounds like you’re saying something similar. In other words, there might be some local health clinics that an audiologist could partner with, including some of those tools like a remote capable otoscope, or an otoscope that can be remotely connected to an audiologist or an ENT somewhere else. So you could do diagnostics in that sort of setting. That seems to be what you’re saying, and that sounds like an opportunity for audiologists to develop a different line of practice in tandem with other healthcare professionals. Am I reading that right? Yeah, that was far more eloquent than I was saying. Well, we’ve talked about innovation in AI, in hearing care in various ways, and I think we could go on for a long time about this. But it’s also something you see on the device side. Everybody likes to say that their hearing devices are AI enabled in some ways, and the most common use for AI and hearing aids has been in sound scene identification, which I have to say is really handy. You don’t have to whip out the app and change programs all the time because the hearing aids are automatically identifying the type of sound scene you’re in and adjusting their settings, you know, to be optimum for this. So you can go from setting to setting, and it works really well. I remember when I first got fitted, and this was in 2018. We went to a loud place, my wife and I, and we were. We had parked down the street, so we’re walking down the street. Quiet. Everything’s good. I opened the door, and all of a sudden, I get hit with a big wave of noise. And about 3 seconds later, it just went. And I was in the noise mode, like, whoa, this is really nice. So that’s very traditional. But now you’ve seen more elaborate uses of AI. For example, the Signia IX can actually identify voices and then track the directional microphones. So they’re using some machine learning, or AI, to. To track the voices. And you’ve got others, Starkey, for one who are actually using machine learning or AI as part of their whole biometric suite. They’ve got, like, an engagement measure. How much are people conversing with other people and engaging this sort of thing. So it’s getting more and more. But now the one we’ve been talking about, Dave, you and I have been talking about this for years and years. We’ve had people on the podcast working towards it is to actually be able to strip the noise out of audio. And people have done it in various non hearing aid ways. For example, if you do a Teams meeting, they’re doing it. They can take out all kinds of background noise, but they’ve got a server farm working. And so there are other people who did it with a smartphone. Like, you could put a dongle on a smartphone, and that interacting with an earbud would reduce the noise. Now you see it in a hearing aid. Phonak, with their Sphere model, just did it in a hearing aid. And if you think about all the ways we’ve been trying to improve speech and noise, this is a novel approach by actually stripping out the noise rather than relying on directional microphones and so on. So that’s the first shot over the bow. How do you see that, Dave? How do you see that propagating through? How do you see all the people who are doing it in smartphones or doing it on computers or servers? How do you see that trickling into hearing devices of all kinds? And how do you see that changes the landscape for people who have difficulty hearing the noise? Yeah, I mean, I think that it’s ultimately, you see these things happen in, like, computers, and then, you know, it kind of takes this path down to smaller and smaller devices, from, like, computers to phones, and then ultimately to wearable type devices. And to your point, you know, I remember seeing this, like, demonstration back in, like, 2018 or 17 of a Nvidia example, where it was this guy that was playing this video, and he was doing, like, a conference call, kind of like what you were describing with your teams meeting, and he had this really loud fan going in the background, and it was kind of like without the AI processing, that can parse the, you know, the two different noise, you know, sound sources. And you could hear the fan. It was really loud. And then, you know, it basically applies the filter, and then, you know, on the other end of the computer, the person that he’s talking to, you can’t hear anything. You can’t hear that fan in the background. And so I remember thinking that was kind of the earliest that I had seen this, and then to your point. You know, you kind of see that progression. And I remember Noopl, like, that thing came around where it was the dongle that you put in your phone. And that was the whole intention of it was that it was a speech and noise processing companion that you would use, that the whole intention was to be able to take background noise and then take speech and identify speech, amplify speech, reduce the background noise, and then you had Chatable apps, and that whole, it was then put into an app, and so you could see how this was making its way to the hearing aid industry ultimately. And then here we are. And with the phonak sphere, I think that that was and I know others are doing similar things. But I think that that was ultimately kind of showing this really having a secondary chip inside the hearing aid. That’s entire purpose, this deep sonic to take the speech from it was speech and noise chip, essentially. And we talk a lot about AI and hearing aids. But I felt like these are the actual applications that we’re going to see, is, if you think about what’s actually happening in real time, the device is able to determine those two sound sources and decipher, and then, without really any latency, have a conversation in real time, and it’s doing all that in the background. And so for me, I’ll kind of flip it back over to you as my go to expert for all things engineering, hardware, chips and all that is this has to be a gigantic technical challenge in terms of how do you preserve the battery life? How does this not become something that just becomes a trade off, more or less. And is there a path in sight to where you can have all day wear for those kinds of capabilities? Yeah, it’s a really interesting question, because the chips keep getting faster and lower power. It’s now in the phonak device, but you can’t run it in, in the speech and noise extraction mode all day. The battery won’t hold up, but normally you don’t need it all day. A lot of your life isn’t quiet. You only need it for the worst situations. But you can see the pathway. And I’m going to ask a question of you two, because as the chips develop, you can see a generation or two from now, you’re going to be able to get consumer grade chips that do this. When you do that, you can open up the applications. For example, we know a couple of different studies. Doctor Beck did one, and NAL did one. Brent Edwards, how many people actually have normal audiograms but have trouble with speech in noise. And we all know that people, even with mild to moderate hearing loss, really struggle in loud settings. Well, you can then start to see this chip ending up in those devices where you only need a little or maybe even no amplification. And yet you can improve a person’s speech understanding and noise, which actually brings up a couple of questions. But the first one I’m going to ask, Steve, is, all right, so a person with no hearing loss or mild hearing loss could really use a speech noise assistance. But for various reasons, stigma amongst them, they do not go and get hearing care services. When you think about how people feel about wearing devices and the stigma it may create, are there any ways that hearing aid designs can be changed or improved or new designs, new looks for hearing aids that would help alleviate people’s feeling of stigma and would get more people than looking for hearing services? You know, I’m not sure if it’s that. It’s kind of maybe a chicken or an egg discussion, like, do you need to change the hearing aids so that people like the way it looks, or do you need to change the way that we look at hearing aids, and then their look is fine? And one example of this that I’ve kind of come across recently is within the world of hearing conservation and musicians earplugs. And previously, there’s been a lot of negative stigma around protecting your hearing. Certainly, as I was growing up, that was an issue, being in some bands, it was, you didn’t want to be the person who’s wearing earplugs. And at concerts, it was similar. Nowadays, there are quite a few companies. Loop is one of them. Eargasm is another, where they have made the most, visually, I guess, exciting, ostentatious earplugs. You can almost imagine, like, they literally have LEDs in some of them that flash, so. And it’s not that people are not putting these in their carts. I’ve gone to a couple concerts recently, and I’ve noticed plenty of, you know, Loop earplugs. Eargasm. Earplugs. So I think it could come down to more of just changing the way that we look at hearing health in general. And then hopefully, the technology and its aesthetics shouldn’t matter quite as much. And how exactly we accomplish that is a different question, a different answer. I do think with this new wave of awareness sound like over the counter hearing aids since August 2022 with the OTC ruling, I think that is actually a fantastic step in the right direction to bring in greater awareness to these issues that we are all, either directly or by one family member, indirectly connected to. And then, hopefully through that, then it doesn’t matter. You can wear the whatever flamboyant hearing aid you want with a. There’s hearing aid jewelry that I’ve seen on Etsy where they’re like earrings that hang off of the hearing aids. And I think that’s wonderful. So I think we’ll see the biggest change when we change our mindset and not the other way around. Let me have your thoughts on that, Dave. I think that obviously. Been part of. I think the low adoption is the chronic stigma that’s been associated with hearing aids. I think that there’s a lot of misguided and misinformed notions of what even modern day hearing aid looks like. I also think a lot of this is generational. I think that the verdict is still out on baby boomers. I think that they might, you know, they’re the biggest generation by far. I mean, if you really look at the numbers, they’re like three times bigger than any other generation. Save maybe the millennials, maybe they’re only double the size of them. But the baby boomers, I think, have an opportunity to kind of buck this notion that these are geriatric prosthetics and instead these are actually ways to preserve you know, your youth, in a sense. And you know, I was telling you earlier, andy, and I think that this might be a good opportunity to kind of tell this story, which is that you know, when I think, I think it’s starting to register with more and more people about the advantages of hearing aids especially if you’re still in your sort of working era not just necessarily from being able to hear things as much as it’s the amount of techs that you’re doing on your brain on a given day. You know, I said that I just saw Tammy Harel, who is with she was with Nuance Audio, which is now part of Essilor Luxottica. And you know, she just put out this paper which was compiling multiple studies from multiple decades really telling this story with data of, you know, the amount of effort that it takes to, you know, for your brain as you have hearing loss, to use all the sort of context clues and conversation as to, you know, what’s going on and being able to decipher that. And I thought that you have a really interesting anecdotal sort of story about your time and how you actually viscerally felt this which I feel like can help to kind of illustrate this point. Yeah. So I shared with Dave and Steve when I first got fitted. Well, I was going, I was working for Knowles at the time, and I was traveling internationally a lot. And I did a lot of trips to China. And when you do a trip to China, usually start off earlier in the morning. I would get up in the morning, I would go run first and then meet somebody for breakfast, have meetings all day. And then there would be a dinner. And since I don’t speak Mandarin, I’m talking to people who have varying levels of English proficiency and various accents. And so even if you’re a normal hearing person, it could be difficult, you know, to understand everybody. Well, before I got fitted, when I knew I needed to, but I hadn’t done it yet, I would go on these. Trips, say ten days and I’d be done. I’d get on the flight from Hong Kong to Chicago and I’d sit down and go I’m pushed. I would just be going, you know, 100 miles an hour for the whole trip and I’d be tired and I thought that was normal. Well, once I got fitted, the next trip to China I made same thing. Except when I was done, it was like, I can’t believe how much more energy I have. I mean, that’s an acid test, to be in that environment for a week or two. But I think that’s actually the story, that’s the better story to tell. I a little bit don’t like the emphasis on dementia because to talk to people, say someone in their fifties who’s still working and is struggling to hear talking about dementia and the foggy future, I don’t know if it resonates, but you can talk about what the benefits are today, how at work you’re going to be more relaxed and you’re going to understand more when you go out with your friends or your workmates, you’re going to be relaxed and you’re going to enjoy yourself and it’s going to give you more energy, you’re going to be less stressed, you’re going to be less fatigued at the end of the day, and that’s going to improve your relationships and it’s going to improve your work life. I think that’s actually the story to tell and not some of the longer term things that may or may not happen, it’s an immediate positive benefit from getting treated. Yeah, I mean, to your point, I think that the that there about the amount of the ability to relax. And so when we’re talking about stigma, I think when I saw the Essilor Luxottica glasses and I don’t know when those will come to market but I think it just sort of changes the notion on what these types of form factors can look like and the type of demographic that might be interested in that versus something like a hearing aid. But I think that the really positive thing that is changing, at least it appears, is that more and more people are coming around to the idea that this isn’t something that’s limited to people that are in their late stages in life, that this can be very beneficial for lots and lots of different stages throughout your life. And the ability to tell those stories, I think, is what’s going to drive more and more people. And it feels like it’s going to. You just kind of can see it in communities of one person gets fit with hearing aids and then it sort of breaks the ice. And I’d be curious of like, what is the tipping point? Like Malcolm Gladwell style, in terms of what percentage of people would need to be fit to kind of break that stereotype once and for all, you know? And of course, that was the goal of OTC, was to get more people and hearing devices sooner. We’re now just about two years on from when the rule took effect. Steve how do you see the OTC landscape? I mean, are they delivering on the goal to get more people hearing care sooner? And how do you see this going a little, you know, in the future? Well, I think first, it’s easy to mention some of the numbers that we have. I think adoption rates for hearing aids, they tend to be fairly low. Like prescription hearing aids, I think it’s around 30% to 40% in the appropriate, and even less for people in the mild to moderate. Right. And even less if we look to other areas. I just took a look at Eurotrek, Denmark, 2022 and some of the adoption rates there for individuals, I think around 70 and above, it was closer to 50 or 60%. So it’s something worth keeping in mind is that adoption rates around the world, even when hearing aids have no associated cost, adoption rates are still fairly low. And that’s no doubt linked potentially with some of the stigmas that we’ve discussed already. But OTC devices, I think it’s a little bit more difficult to find information on them because there is no overall governing body or organization that collects that data. So I don’t think a lot of it’s public, but from what I’ve heard, adoption rates are certainly lower than what prescription hearing aids are. And then return rates are probably double or a little bit more than what they are for hearing aids. So without that out of the way, I guess you could say, like, are they delivering on their ability to offer similar benefit as prescription hearing aids? And that is a big yes in some, some ways. And that is also a big no in other ways. And what I’m trying to highlight here is that there is a broad range of quality among OTC devices. For over the past two years, I’ve tested somewhere in the ballpark of 80, 90 of these devices, ranging from ones that you can purchase on Best Buy, on Amazon, through Walmart.com, and a lot of the other ones alongside prescription devices. And some of them do perform very well in the mild to moderate range. We don’t do any testing outside of that because that’s not the intended purpose of these devices. And something worth noting with regard to that statement is that shouldn’t really be of a surprise that some OTC devices do well, because many OTC devices are actually just prescription hearing aids that have been redesigned for the over the counter, direct to consumer market. So I don’t want to say that they’re limited, but they are simplified to a certain extent to make things easier for consumers. So for those devices, we have found pretty much across the board. Again not very surprising that performance is, is very good. The ability to meet a standard or a very common age related, mild to moderate sloping hearing loss is fairly easy. Some of the settings on these devices do fairly well with making speech clear. For example, streamed audio quality is fairly decent. And that kind of, I guess, closes off that category. So on the other side, which is the no category. We’re not delivering on it. And I know there are certain standards, output limitations for OTC devices and all that. But I have tested some devices that the one that sticks to my mind, sticks out in my mind. It literally functioned. So let me start. It looked good. It was around dollar 800. So it’s not cheap. It looked like a hearing aid, a slim tube hearing aid maybe from 2015, rechargeable, really nice case. And when we tested it, looking at the insertion gain, it pretty much had a low pass filter at 1.5 khz. So if you can imagine like the plot going up, here’s 1000, then the device just drops off, providing absolutely no gain above that point. And this was one of those OTC devices that ships with a, shipped with a very occluding It’s kind of like a tulip power dome double flange with slats in it. It’s a very common thing. MD hearing uses them quite often. But it’s rather occluding. So what I’m getting at is this hearing aid looked good. It had a high price, which I think from a psychological buyer standpoint, you would think then there’s also going to be higher value associated with its abilities. It didn’t provide gain above 1.5. Not only did it not provide a gain, it arrived with an earplug ear tip that was very occluding. So it was actually exhibiting insertion loss at 3000 hz, which is the most important speech frequency range. And I may be describing it poorly, but like, that’s the exact opposite of what you want for a hearing aid. A hearing aid that’s actually blocking sound in the most important speech frequency ranges. And I can’t really imagine what a consumer would think and experience when they were to be fit with a device like that. Because again, it costs good, it looks good, website looks fine. So that’s kind of the range that we’re seeing. Some devices are very good, some are maybe certainly underperforming prescription devices from a sound quality standpoint, but they’re also much cheaper, so they offer a decent value. And then some devices that are potentially impeding speech intelligibility benefits. So what you’re really saying is it’s still a minefield out there and it’s difficult to sort out. It is. And if we were to group it by cost, some of the things that we’ve seen in the sub $500 category devices are generally not great, which makes sense. If you go between the $500 to $1,000 range, there’s a very, very broad spectrum of devices where some perform very well. Many of those could be the repurposed prescription devices, for example. But then some of those are also offering very little benefit and still costing like, $800, like that one that I previously mentioned. And then once you get above around $1,000 performance kind of saturates. And all devices tend to perform well, which is certainly what you would hope when you’re spending that much. Okay. And so, Dave, in talking with all the audiologists you do, are you seeing any practices who have integrated OTC in their practices? You know, you think about the person who comes in, they’re diagnosed with mild to moderate hearing loss. They’re like, you know, I can hear well enough. I’ll get back to you. Are there practices integrating OTC to help adoption rates in their own clinics and like, share some best practices of those that are, if you’ve seen them? So to be perfectly honest I don’t know of many, if any that are I mean, it’s not to say there aren’t, but I think that it kind of, you know, if you’re going to go and see a provider it kind of begs the question of why would the provider push you toward an OTC and not a lower cost you know, prescription hearing aid or, you know, help you find a benefit something to that effect. But I think that when you’re looking at this whole thing and you see these high return rates, I kind of think that that implies, as Steve is saying through Hear Advisor, they’re doing all these very objective measurements of the performance of these devices. And to his point, you have some that are good. And so I’d be curious to look at some of these higher quality devices, what their return rates look like. But I think that that example, there is a perfect example of where you kind of need professional intervention. This is the value of the provider is to make sure that the coupling of the dome itself is fitting properly so you’re not just kind of defeating the whole purpose of that style of hearing aid. And so I think that the role of the audiologist as it pertains to OTC, I think might be more like what you could see happen is the audiologist actually would potentially contract with an OTC provider where the OTC, or, I’m sorry, the OTC manufacturer. So the OTC manufacturer recognizes that there’s value in the professional. But the professional isn’t going to go out of their way to push that product unless that product is like, it’s kind of facilitated by the manufacturer and you’re, you’re brought in as like a third party professional to provide that service. So I could see that being a more viable sort of way that the audiologist could be involved in the whole OTC space. But frankly speaking, I think if they’ve walked through your doors they’re not really an OTC candidate as much as they’re a candidate for your services and whatever, you’re gonna push them in, and you’re probably going to be pretty, you know, agnostic as to whether it’s, you know, you’re just going to push them toward the. The type of treatment that they need. Not really paying mind to is this. A quote unquote OTC, or is this a quote unquote prescription hearing aid? So that’s how I kind of see it, is that it doesn’t, it’s one of those things that it’s, like, kind of premature. But I’m happy that it’s here. I’m happy that it’s been rolled out, because I think that you have to have a starting point to iterate and to improve on. I think to Steve’s point, it’s done a good job in generating awareness and helping more people understand. You know, that there are lots of different options. You can probably even tell a story with the data as to how OTC has maybe even grown the prescription market. Because I think maybe more people are waking up to, you know, I have a problem here that really does warrant medical intervention. This is a medical problem that needs a medical profession, professional. Okay. And I can kind of loop around to the very beginning when we were talking about automation and diagnostics. So you have, you know, increasing automation and diagnostics. You have OTC out there. Steve, how do you see a clinician today being able to communicate and actually use their true value with patients when they’re coming in with, you know, OTC on their mind, and you’ve got changing ability to do diagnostics automatically? How do you actually see hearing care professionals successfully communicating the value that they truly bring? You know? I guess one thing that comes to mind is, back when I was in clinic, I would frequently have a few patients that would always bring in a little pamphlet of some device that they got through or some advertisement they got through the mail, a newspaper clipping. I think we’ve all had that happen before, and it was one of those situations where I would always be honest with them and just tell them, like, I do not know. This is not something that we are, like, educated with regard to in school. It’s not something that we get our hands on for testing. So I don’t have any, like, anecdotal evidence. But with regard to, like, I guess, navigating some of these technologies within a clinical setting, I think it’s worth noting that there are some resources, such as hear advisor, where you can see what their performance is in those cases and reach out to the patients and let them know. And there’s always this discussion. I’ve spoken with a few audiologists, so it seems like there’s maybe two thought processes, and there’s one school of thought where if you want better hearing, you find a way to get the money for whatever device it is that’s being recommended. And the other school of thought is there are some people who just genuinely do not have the finances to get appropriate hearing care. And it breaks your heart in those cases. And that was what I personally experienced regularly at a nonprofit, we would regularly work with the Lions Club to get donations, and they would offer, like, a grant for a monaural fitting for a few hundred dollars, and then as a clinic, we would say, we’ll match that so you can get a binaural. Fitting, because, of course, we believed in binaural fittings as opposed to monaural. And after what would seem like a symposium of counseling and explanations, as I’m sure many of you have had as well, people will still say, I just want the one. And they’ll say, oh, I’ll come back once we find enough money to garner, too. So I don’t know how far off topic I’ve gotten, but I think there are some things that we can do with educating ourselves for these technologies and maybe narrowing it down for those people who might not have the funds to say, okay, we know that this subset of devices is fertilizer. These are the devices that are great, but they are very expensive. And here’s maybe a bubble of technology that falls within a viable a more accessible price range while still offering viable hearing health. And then, I guess to Dave, what you were saying then, you can still function in a clinical setting. There’s nothing saying you can’t perform real ear measurements on these devices and counsel the patient. And so much of what we do clinically is letting the patient know what their expectations could be for best outcomes. Well, and that’s I want to ask the question in this light. If a person orders a self fitting device, even one that’s good performing and does it all at home, what are they missing versus going into a clinic? So, I was reading an article by Douglas Beck recently, and I really liked, he brought up the notion of diagnose first, then treat. And I absolutely agree with that. So what you’re missing out on going straight the OTC route is, of course, what actually is your hearing profile? And not just your, you know, absolute thresholds of hearing, but speech capabilities, more cognition. What is it within your individual life that interests you? Music needs? Hearing conservation. For example, maybe you have hearing loss because you’re a woodworker and you’re using a table saw constantly. So, yeah, there’s a lot more that goes into it. And I know I’m preaching to the choir here, but those are the discussions, I think, that end up being missed. Simple things like when I started in clinic, just how you pose certain topics. You say, oh, when I put this hearing aid in your ear, your voice is going to sound weird. Tell me how we can fix this, and we’ll work on it. That’s a very different clinical style than when I put this in your ear. It’s going to sound different because now you’re hearing yourself not just through the bone conduction pathway, but also the air conduction pathway that you haven’t been hearing because of this peripheral hearing loss. So all of that goes into how your patient’s quality of life can ultimately change, because it is vastly more than just the technology. And in our kind of discussion leading up to this, I think that’s what we ended up landing on. Like, there’s no doubt a reason why return rates are so high with OTC, even if they are a re-boxed version of a prescription device, you’re missing out on everything that you are providing to them and more. Okay, so it’s. Really, if I think of the original question, how hearing care professionals can communicate to their patients what the value is in seeing a person in person versus just buying it out of the box. Thinking about the rehabilitation that comes afterwards, thinking about personalizing the hearing experience for their lifestyle. These are sorts of things you’re thinking. Sure. And I can give another example, and this is an analogy that we’ll all be familiar with as well. You fit someone with a new hearing aid you tend to not put it at 100% prescription. Meet NAL-NL2 targets within a few decibels and then send them out the door because you’ll see them in 15 minutes, if it’s too loud. The goal is to, of course, acclimatize them to this darker world of auditory deprivation that they have had for 20, 30, 40 years. And their brain has just become so comfortable and familiar with that silence. And a common analogy is you’re sitting in a dark room for 40, 30 years, you step out into the sun, it’s going to be too bright and too intense, and it’s going to take time for your visual system to adapt to that. Unfortunately, the hearing system is going to need more than a few, a few minutes or a few seconds even. It’s going to take weeks to do that. And I think this is one of the biggest areas that there’s many. So I could say this for everything, but let’s say this is one of the biggest benefits of going to see a provider. The analogy I like to use is it’s like physical therapy. If you’ve injured some portion of your body or you had surgery, heart surgery, and you need to go to some type of cardiovascular rehab, breathing rehab, muscle rehab. They are provider there that’s going to know how much pain is actually good. If the muscle is broken, they’ll work you through range of motion, know how far to hurt yourself, basically where the muscle is being torn just the right amount so it can heal, so that the next time it can be pushed a little bit further and a little bit further. And even if you never get back to the full range of motion before the injury, you know that you’ve at least everything’s out on the table and you’ve optimized it and you haven’t hurt yourself in that journey. And I mean, that’s the beauty of being a provider. You get to hold people’s hands through that. And I really do think you can do that with an OTC device as well. It’s just, I think from a consumer side, it’s so confusing. It’s still very expensive, so it’s finding a way to mitigate both of those barriers. And then from a provider side, you’re all extremely busy. Its one of the reasons why I got out of clinic. You’re not even given time for yourself to finish reports and do billing and all that. But then you need to have the knowledge somehow of what devices are worth even trying to fit your patients with. And that just sounds like a shameless plug, but really, that’s what we’re doing it hear advisor trying to provide that information for you. Well And one of the things that I hear from hearing care professionals often is they get frustrated because they have to be the genius bar, helping people connect their hearing aids to different devices. And now we have LE audio and auracast coming. Dave, how important do you think that’s going to be? I think that, well, learning from you I actually think this will be a huge boon, obviously for patients, but I think it’s going to be really big for the professionals too. Im going to kick it to you so that you can actually, because you just wrote Gus Mueller’s 20Q on Auracast, the expert on this stuff, please explain from the universal standard and what’s actually happening with the Bluetooth protocol and why that’s going to make every person in this room’s life easier. Okay the short version, there’s actually This Week in Hearing podcast if you want the long version from a presentation I did in Australia. But the short version is except for Phonak, who did Bluetooth classic for the streaming part. When hearing aids are connected to your phone, it’s not actually Bluetooth. People generally say, oh, you’re connected to Bluetooth with your hearing aids. It’s not official Bluetooth. And the hearing aid companies don’t say it is, they just say connectivity because there’s an organization called the Bluetooth Special interest group that creates the Bluetooth standard. And if you want to say you have Bluetooth, you have to submit your device for testing and they approve you. And this is why today Bluetooth works pretty good. If you go buy a Bluetooth earbud and connect it to your phone, it’s actually pretty easy these days because everybody has to meet the standard. The problem with Bluetooth classic was too much delay and power hungry. Okay, Phonak solved the power hungry part for streaming, but not the delay part. So for example, if you use a roger microphone, it’s still using a proprietary system with lower delay. You can’t use Bluetooth classic with a remote microphone. And everybody else is using proprietary systems for everything. So Apple has MFi and Google has the unfortunately named ASHA. Right. Confusing with the organization, but those are proprietary systems. And the problem with the proprietary system is I believe that the phone companies don’t really pay enough attention to them. So you see operating system changes, right? Update to iOS 14. All of a sudden all the hearing aids are disconnect, right? Because there’s nobody minding that store. And the hearing aid companies are frustrated too, because they have to go back and figure out what the phone manufacturer did to mess it all up. And they’ve got to adapt accordingly. When you have LE audio. The delay is lower, useful enough to use with hearing aids now, and it’s a standard, so anybody who gets the Bluetooth blessing is following the standard. So we should get away from all these sorts of connectivity problems and issues going forward. So LE audio, I think, will give a much more uniform. Connectivity experience. I mean, imagine you are actually at the genius bar and somebody wants help pairing their hearing aids to their phone or pairing their earbuds to their phone. You almost don’t have to know what the earbud is, right? You put it in pairing mode, it connects to the phone. It’s all very automatic. It should get that way with hearing aids as well, uniform, regardless of what. And then there’s auracast, which is the broadcast. That’s something completely new. Now you have a version of Bluetooth that every one of you in this room could tune into at the same time. In a nice reverberant room like this, it would be great to have auracast, right? Just pop in an earbud or flip on your hearing aids into auracast mode and you could listen to the direct stream audio. So it’s, you know, an assistive listening system that’s a lot easier to implement because this room. So when I did the demonstration in Australia, there’s an australian company called Audeara. Some of you may know them because they make headphones that a hearing care professional can actually tune for a person’s hearing loss to improve the music experience. They were demonstrating a pre production auracast microphone. The whole thing was about that big, you know, just a little clip on microphone and it would easily cover his room. The room I was presenting in there was bigger than this. And we tried it. I went all the way to the back and I was still getting coverage there. So a little device you could clip on would then stream auracast this entire room. And anybody with an auracast capable ear bud or hearing aid could tune into it and get my direct audio. So I think that part’s going to be really huge. Consumer devices are going to drive it in a lot of ways because it’s so easy to transmit. Imagine now you have three sports bars in town. One of them puts auracasts on every tv. So when you go to a sports bar, you can actually listen to the audio on the match over there. Now that’s a mass consumer demand, and that’s going to drive increasing installations of auracast. And so then people who have hearing loss as well and are wearing hearing aids are going to get the benefit. There’ll be so many more installations of auracast than there are with other assistive listening devices. I guess that wasn’t quite the short story, but it wasn’t too long. That was perfect. Very succinct follow up question for you with regard to that. So I know looping systems are common, and they have many benefits. But one concern would be based on how you place the loop. You might get some crossover into another space, and then an individual, maybe on that side, gets some pickup that they don’t want. So how would that differ with auracast? Would there be, you know, with, like, Bluetooth microphones, for example, different, like, channel hopping? Where. Which would avoid that that issue with, if there’s somewhere over there, someone over there, they still want aurcast, they’re able to put it in a different mode so they can hear that speaker as opposed to you. Yeah, it’s. Think of it as broadcast radio. You can tune your radio to any channel, and they don’t interfere with each other auracast is like that. So when I did the live demo in Australia, I had two channels running. So it would take. My phone, my galaxy S 23 will tune it. So I went just like you do Wi Fi. You go Wi Fi, open Wi Fi networks, and you connect to one where you go, what auracast channels are there? Two channels were listed. I picked one. Boom. I was hearing it. And so it works like that. And so you can actually have, for example, in this setting, if you wanted to translate to a second language, you could have a person, you know, doing the translation, and it would be on a separate channel, so you could tune into either language. Chuck Saban at Bluetooth SiG gave a really good example how it could be used in live theater. One channel broadcasting the normal audio, so you lose the room resonance and get clear audio. You might have a dialogue enhanced audio, so you’re dimming down the music and the rest of the score and accenting the sound, which, in a movie theater is important because, like, an action movie is so compressed and there’s so much going on when people are speaking, it’ll be pretty hard to. So you have dialogue enhanced audio, and there are places now that are starting to do descriptive audio for low vision people. So you’re watching live theater and getting descriptive audio. Or imagine you go to a baseball game where you’re getting the radio feed. So even though you’re low vision, you can’t see what’s happening on the field very well. You’re listening to the radio broadcast through your aura, gas earbuds with no delay at all. So you’re hearing the action as it’s happening. So lots of opportunity there. But because it’s multiple channel, you just tune into the one you want. You have multiple channels in the same room, like the sports bar. There’s no such thing as bleed over. Where are we with the deployment and the rollout right now? I mean, where are the I guess, the obstacles in terms of mass deploying this? Is it the transmitters, or can you help us understand? Like when will we kind of see this at the masses and what’s kind of preventing it from happening? Next week. You’re really good at turning the table. I’m the moderator now. So I see it as three tracks. There’s personal, there’s multi screen venues, and then there’s single screen venues like theaters. So personal is already happening. So I did, like, a short video demo where I took one of the GNTV streamers that broadcast oracast, and I took my Samsung Galaxy buds and tuned into it. So the tv streamer exists. They’re actually either Samsung or LG tvs are now broadcasting or cast directly out of the tv, so you don’t even need the streamer. Earbuds are coming online, so JBL just introduced one with a smart case, actually. So the battery charging case has a little screen on it, and you don’t even need a phone. You can select the oracast channel off the little screen of the charging case of the earbud. Samsung has it. Theres a couple others that have it too now. So earbuds are coming, tvs are incorporating it directly. You can attach a tv streamer. You can do le audio on newer intel PCs now. So if you want to, you have an le audio capable ear butter hearing aid. You can tune in, including advanced hearing aid controls. So this is coming with Windows Eleven’s next upgrade, which should be coming right around now. But intel gave me a PC that had the beta version in it. I took it to Australia with a set of gnexias, which are already le audio capable. Right from the hearing aid or right from the computer, I could change the mode. So, for example, I’m having an Internet meeting. I want to put it in streaming mode so the outside sounds are all dimmed. And I’m, you know, focusing on the audio coming from the streaming. A couple of taps and the computer puts the hearing aids in that mode. I want to then talk to somebody who’s in the office with me, for example, I could switch them into normal automatic or omni mode, and then I can hear all around me and whatnot. They even did a demo, and this is coming with their new processors that’ll be rolling out pretty soon. They’re actually doing some of the AI stuff in the PC. So if, for example, I’ve got them in focusing mode and I’m just purely tuned into the audio in the Internet meeting, somebody knocks on my door, a little pop up on the computer screen pops up and says, someone’s knocking on your door, and automatically throws the hearing aids into omni mode. So there’s actually some pretty cool things going on there. And so this sort of personal space is happening now. You can do aura cast at home with your tv. JBL has got their Bluetooth speakers that do aura cast. So you can scatter three or four auracast speakers around and all play the same, that sort of thing. I could have an oracast capable earbud or hearing aid in while somebody’s listening to the speaker. That’s happening today. I think the next one will be the multi screen venues like health clubs and sports bars, because that’s mass market appeal, right. The first sports bar that puts an oracast has a competitive advantage over all the others. The health club that has oracast and all the tvs on the wall, you know, will be more attractive to people, versus the health club, where you can’t hear the audio on the tvs, that sort of thing. Then I think I come to theaters because they already had to have a system in place because of the ADA. So theaters already have an assisted listening system. Theyre not always very good. I mean, and Gail Hannon and Sherry Eberts will talk about that all day long. How many venues they’ve gone into where the system is garbage. But they’ve checked the ADA box. And because they’ve checked the ADA box, I think they’re going to be the last ones to make a new investment. Now, one key is that it’s perfectly compatible with other systems. If you have a loop, for example, you can add oracast to it, and it goes the other way, too. The hearing aid companies right now, GN is the only one who actually does it. Pretty much all the others now have the capability built in and they’re just waiting for it to become a little more mature before they turn it on. But many of the hearing aid manufacturers are including loops as well. And I think that’s important because in the public venues like theaters, it’s still going to be some years before deployment is really rolling. Transmitters capable of working in a theater are not even available today. They will be before the end of the year. So you can see this rollout being slow. So, like for you who are hearing care professionals, I would say if a person, when you talk to a person, they like to do things like go to theaters and the theater in town has loops, I would get them a hearing aid with a t coil, even if it’s also orcas capable. Now, you’ve got systems in place today you can tune into and your future proof of oracast. So those are the three steps, personal, you can do it today. Multi screen venues, I think will be next. And then single screen venues like live theater or movie houses would be last. We’ll see if I’m right. Come back in a couple of years. Okay. Now I’ve been talking about, you mentioned it several times, hearing protection and you know, the prevalence of noise induced hearing loss, of which I’m the first to admit, a lifetime of going into rock bars and live venues when I was younger got me in the state I’m in. Of course, it’s better to prevent hearing loss than to get it in the first place. But from a hearing care professional standpoint, what tools are now available that hearing care professionals, as part of their practice, can address noise induced hearing loss and actually add that as another dimension to the value they bring. I think that first starts with just some general education and I don’t know where everyone, you’ll need to assess that on your own. I know when I was in school, I had probably three or four classes on pediatrics, and I should never be doing pediatric audiology, and I only had one class about noise and its effect on humans. So there are, with that said, many fantastic resources to learn. I know Doctor Santucci is here and he has a class for that. That went on earlier this morning. But outside of that, and just having greater general awareness of sound, its effect on humans, sound induced or music induced hearing disorders, that it is not just a decrease in hearing loss, it can start off more in the realm of cochlear synaptopathy with like hidden hearing loss. So all that out of the way. I guess there’s a few simple more gadgets or tools that you can use, the simplest of which is just musicians earplugs and whether or not your clinic offers them to patients and is asking on a regular basis, not just do you have sound exposure? No. Okay, good. Most people will say no. And then you ask, how do they. Know if I’m a hearing care professional? How do I tell my patient? How do I give them the tools to know if they’re in an environment that’s too loud or I. Well, so just speaking with them. But I can give you two great examples that are perfectly free, very simple, and everyone should have one, if not both, on their phone. The NIOSH SLM app comes from the National Institute for Occupational Safety and Health. They have a fantastic app that gives you great information. You can actually calibrate this app to be class two sound level meter. If you use an external thunderbolt microphone, like the w mic I 437 l, it’s like $100 if you use a 1 khz calibrator with it. Again, you can get up to class two, where there’s, like 2.2 decibels. Of error, which an ordinary consumer is not going to do. Is it accurate enough without doing that they should? No, that’s okay. No. Is an audio geek like me. You don’t have a calibrator in your pocket. So NIOSh is great because it gives you information about Laeq instantaneous levels education on there with regard to what all of these terms mean. It also allows you to use the app as dosimetry. And this is something in some of my classes that I have the students do where they wear it in their pocket or somewhere close to their ear, because that’s where measurements are important, and then get a sense of what their daily dose of sound is or their weekly dose is. So that’s one app. There’s also decibel X, which is cross platform iOS and Android, where NIOSh is unfortunately only iOS. But Decibel X also gives you a real time analyzer. So a spectrogram, which can be then used to make better inferences about the noises that you or your patient are exposed to. And generally the way I describe it to people, because, of course, it’s a time intensity trade off. It’s like sun exposure. It’s not like you get sunburned once you have cancer, but that makes you more likely to have skin issues later on. Certainly the more you have hazardous sun exposures. But generally 85 decibels is a good danger zone, and you tell people that and just let them know if you’re exposed to levels beyond that, you need to step up the level of protection. Now, one extension to that that is very clinical, very easy to do is real ear attenuation at threshold measurements, or reit, as it’s called, which comes from an ANSI standard S 12.6. You could probably complete it in, like, ten minutes. And there actually is a CPT code for it, 92596. This is basically performing threshold measures, open ear and sound field. Then you plug the individual and you perform those same measures again, and then you take the difference between them. And this gives you what’s called insertion loss. And it gives you not just an estimate of what that earplug will do, like what the manufacturers publish, or NRR, which we know is inaccurate, but it tells you how that earplug functions on their ears. And then after asking about what their nose exposures are, is it occasional woodworking? Occasional music? Are you the drummer of a rock band? Do you go to occasional concerts? You can work kind of forwards and backwards from there to find appropriate hearing technologies using a cell phone app. To more or less figure out what those sound exposures are and how much protection is appropriate. So you could actually arm a person with a mobile phone app so they can measure the noise levels like at a concert. You could fit them with hearing protection, you can verify that they fit properly and you’re getting the attenuation. And then of course I did an internship through sense of phonics with doctor Santucci when I was a student. The important part is coming back to make sure that what you have in your ears and how you’re employing hearing conservation measures, because of course it’s more than just wearing earplugs, but making sure that it actually works. And I can give you one example of that. I mentioned going to two concerts recently, Metallica and soldier field in Chicago where I was, it was 100 dba. So if you go by OSHA standards, you have 2 hours before you’ve received your full daily dose, which is not too bad. I went to another concert shortly afterwards in the Concord Music hall and this was protest the hero, so progressive heavy metal. Average sound levels were 109, 109 decibels, which means you have two to three minutes if you go by NIOSh, which we all should before you have received your full daily dose. And then the example that I wanted to mention in this story is between sets, between bands, you think they would turn down the volume, give your ears a break. Which is a common recommendation to help again, decrease your overall daily dose. They were pumping music through the PA system at 95 decibels, so you couldn’t even really use that as a safety. And when you’re that loud, my idea is even if you wear ear plugs that are appropriate, if you factor in OSHA’s 50% NRD rating or NIOSH’s 70% derating to get more accurate field ideas of the NRR. It doesn’t matter how much hearing protection you’re wearing, you’re still subjecting yourself to potentially hazardous sound levels. So it was something, it would be something. I would love to see change in the states where we are more aware of this and we actually care about our hearing system so we don’t have to rely so much on all these other technologies, which are great, but if we could avoid needing them in the first place or avoid needing more severe assistance from them, that would be fantastic. That would be very nice. Well, I see we’re almost out of time. I want to open it up in case anybody has any questions. It’s been a fairly wide ranging discussion. Love to have your questions, if you have any. Thank you.