My solar-powered alarm clock/DVD/CD/MP3/AM/FM/TV/iPOD system plays my current favorite song -- to gently stir me from my slumber. I go to my sleek and stylish bathroom to wash up. The time-sensitive-motion-detecting shower turns on to the preset temperature, the toothpaste is dispensed from the wall onto a toothbrush, and as I smile, it perfectly cleans my teeth. Unfortunately, the auto-floss function is not working and therefore, I resort to a rather primitive manual flossing method. My outfit is hanging in my self-pressing closet. I dress, kiss my husband and grab breakfast on my way out the door. The meal-in-a-bar-du-jour was pretty good. The food dispensing system automatically replenishes the meal-in-a-bar stock, and we're ready for another week of breakfasts to go.
My environmentally friendly car runs on hydrogen. It skillfully manipulates itself through busy rush hour traffic as I read www.audiologyonline.com on my portable wireless mini-laptop (PWMLT) and the automobile quietly and quickly deposits me at my office door.
I walk into my thriving audiology private practice. I should mention that I actually do both ears, not just left (L) or right (R). Although I thought the move to ear specific specialization (ESS) was interesting, and I certainly understood the need for the "L" versus "R" subspecialty, which was recently offered as an additional certification program via the National Audiology Academy (NAA), I have not yet chosen L or R, and so I still see patients with binaural and even bilateral problems.
The L-ENT (left ear only, ear, nose and throat doctor) from the office next door brings a cup of Starbucks coffee to me. She has apparently been waiting for an unscheduled consult for a few minutes and she is not accustomed to waiting! Some things never change. She is a little nervous about the outcome of her surgical case from yesterday and needless to say, she respects me and treats me as an equally contributing professional colleague, even though I see right ear patients! The L-ENT updates me on the result of yesterday's completely implantable, inner hair cell cochlear implant (the IHC-CI) and my professional day begins. I agree to squeeze the patient into my workload this morning to program the device.
My first patient is a thirty-five year old man, a victim of TP (trendy piercing). His left eyebrow presents with a gaping wound, causing his eyelid to sag. He carries a small towel to wipe the drool from the hole in his lower lip. The one-inch hole in his left earlobe and the scarring along the left helix is not uncommon for TP victims. The metal bar that previously inhabited his tongue left his front incisors chipped and his speech impaired. Twelve years of heavy metal music and thirteen more of punk rock have undoubtedly created a classic noise induced hearing loss. I insert the probe tip into his ear ...and I reminisce about 2005....aaaaah the good old days....
I was in my first year of my Au.D. program. We learned so much! Psycho-acoustics, audiometers, hearing aids, cochlear implants, neuro-anatomy, neuro-physiology, admittance machines, otoacoustic emissions, auditory brainstem responses and on and on....and of course, the necessity of the complete diagnostic battery. Thank goodness we learned about complete test batteries and the importance of the cross-check principle! So many incorrect and missed diagnosis have been attributed to "pure tone only" and "screening" tests and silly assumptions made based on partial data collection!
Thank goodness for the mandatory "complete audiometric evaluation (CAE)" legislation signed into law in 2009! Although I was originally concerned about over-referral and unnecessary testing, now that the entire auditory behavioral and neurophysiologic analysis can be accomplished in less than three and a half minutes...it seems like a very good idea. I really like mandatory newborn screenings at birth, with mandatory CAEs at 12 and 24 months, and again at ages 5, 10, 20, 40, 50, 65 and 80. I also like that all 50 states mandated "normal" or "corrected hearing" laws which address the issue of manually driving the older diesel and gas powered vehicles without normal audition! What a fabulous step forward!
Although we were so up-to-date with technology at Central Michigan University back in the earlier part of the 21st century, I could not have imagined how different practice would be in 2010. We no longer have bulky audiometers or admittance meters, and there are no dedicated auditory brainstem response units or dedicated otoacoustic emissions equipment.
The entire CAE hardware is my "audiology laptop," mentioned earlier, the PWMLT. It has everything, does everything, and is automatically updated every time I log onto www.audiologyonline.com
Here I am, just two years out of graduate school and already I have been to 431 continuing education classes to learn about the ever-changing new technologies in hearing sciences. Who would've thought that everything we learned could be drastically modified and reshaped constantly?
The 35 year-old TP patient is finished. The diagnostic testing is over and there is no need for CT or MRI studies -- this is clearly not a retrocochlear case. I explain the results; noise induced hearing loss. And as is typical, of course, he will do fabulously well with amplification. I gave him the "instant-fit" CIC versions for his one week trial period. Although he wanted to purchase the CICs instantly, I recommended he try them in a variety of settings before purchasing them. He reluctantly agreed and scheduled his follow-up for one week from today. I referred him to the facial plastic surgeon across the hall for his TP issues. Now that he has been audiologically cleared, he can proceed with his medical appointment.
Ever since the American Health Care System (AHCS) dropped its territorial barriers and turf battles between professions and professional academies, professionals have focused on healthcare and evidence-based outcomes, and referral based on need. The previous patient needed a referral, so I referred him. Politics has no role in healthcare in 2010, and frankly, it's hard to recall how HMOs, PPOs, and federal and state programs actually made any sense at all. Looking back those systems seemed very wasteful, inefficient, arbitrary and politically motivated and driven. I can hardly believe that Medicare patients were previously forced to go to medical doctors for hearing problems! Did they have to do that for dental problems too, or could they just go to the dentist for a dental problem? It's really hard to find those answers now that people no longer get cavities and there are hardly any dentists in practice any longer. Ever since the cosmetics counters at the better department stores started taking over dental cosmetics, dentists have pretty much retired or gone into medicine and veterinary sciences, using the distance education models pioneered a decade or two ago through audiology.
The PWMLT reads aloud the latest hearing healthcare news from Audiology Online. I generally use the English accent playback option to listen to the latest news. Apparently there has been a major signal-to-noise development...new ultra digital CICs now offer 35 dB signal-to-noise ratio enhancement. "Not too bad!" I say to myself.
I see my next patient. A 13 year-old boy with apparent sudden sensori-neural hearing loss. He has recently been doing poorly in school and was referred by the school counselor. His mother brought him in for the first time today. We chatted about school and his classes while I collected his case history; partially from his mother and partially from the boy. There was no history of hearing loss in the family, nor was there a significant medical history.
We begin his CAE with microscopic video-otoscopy; he had clear canals and tympanic membranes, bilaterally. Tympanometry was within normal limits. Acoustic reflexes were present at all frequencies ipsilaterally and contralaterally between 80 and 90dB SPL, bilaterally. Pure tone thresholds indicated a flat 75 dB HL sensorineural loss, bilaterally. Otoacoustic Emissions were completed and revealed robust emissions at all frequencies in both ears.
I counseled the mother and boy regarding inconsistent results, the need for further testing and the possibility of a "behavioral overlay." The mother shot a look at the boy that I could not have imagined! She was steamed! I offered the boy the opportunity to retake the only behavioral portion of the CAE -- the pure tones. I explained that sometimes kids don't really understand the instructions the first time. I gave him the option of re-doing the pure tone audiometry portion of the test battery, now that he "more fully understood" the instructions and the goals. I explained that if the results were more consistent, we could perhaps avoid ASSR, ABR and perhaps we could avoid the CT or MRI too. I explained to the boy that in cases of unexplained or inconsistent results, we needed to rule out other, perhaps more dangerous etiologies. The boy agreed to re-doing his pure tone test. To no one's real surprise, his thresholds significantly improved over the last four minutes and were now within normal limits. I referred the boy and his mother to the school psychologist for follow-up.
My last scheduled patient of the morning was a 50 year-old, attractive professional woman, presenting for initial mapping of her cochlear implant. She had a difficult time deciding whether to first have left or right surgery. Of course, she'll wind up with bilateral CIs anyway, but she really struggled over which side to have done first. It was a matter of which ear she preferred to use with her cell phone. She saw the L-ENT and the R-ENT, and of course there were endless options and alternatives available.
Nonetheless, the minimally invasive office procedure is frankly, no longer a hot topic - now that CIs are available for $299 each and they only require local anesthesia and a 6 minute procedure, they are fairly common. Many people have their CIs implanted at the same time they have their corneas replaced, and the ENTs still seem to compete with each other for surgical patients. I guess some things never change!
I described what the auditory sensation would be like. She nods and giggles in anticipation and then I turned it on. We did her initial mapping, all electrodes fired, no problems. The appointment was filled with "oohs" and "aahs" and tears of excitement and giggles from sensations she had not known previously. Within a few moments we had her post-op CAE completed and her results were of course -- strinkingly normal. 10 dB speech reception thresholds and 100% word recognition scores. Although she knew there would be adjustments to accommodate the different languages she listened to, she left as a satisfied and happy patient. We rescheduled her for follow-up in 30 days to fine-tune the instrument, and set her ten-year appointment for her "decade done" battery replacement.
As I reviewed my day, I finished my reports and notes and listened to the latest instant memo from www.audiologyonline.com. Dr. Beck was interviewing the President of the United States (again) and both of them appeared to have English accents. I turned off the "England" setting and listened in "American English" to the discussion about how the President had successfully achieved world peace and international democracy quickly after overcoming his precipitous sensorineural high frequency hearing loss, while using the new 35 dB signal-to-noise digital CICs and an FM system. It made me proud to be an audiologist.
At times, it's hard to believe where I am today, in 2010. I remember 2005 so clearly, and thinking graduate school would never end. Even though I am finally a real doctor, and school has ended, my education goes on. I try to learn something new every day. I experienced all I could professionally during those years in graduate school, but now in my private practice, it's all new again.
As I was about to hang up my labcoat for the morning, the phone rang. A woman was crying. My cochlear implant patient from earlier this morning had just returned from lunch with her husband (they went to a noisy restaurant and she heard every word) and when they arrived home, she experienced her daughter's voice for the first time. She phoned me to tell me the joy her CI had brought her. Her enthusiasm and joy sent chills up my spine.
The quality of life and opportunities we facilitate as professionals has never been better. The future has never been brighter for patients, professionals, and of course for the rest of the world too! Being a doctor of audiology in 2010 has allowed me to fulfill my dreams and aspirations and has allowed me to help others achieve their goals, too. I can only imagine what it will be like to be in practice in 2020.
