Interview with Robert Dobie M.D., National Institutes of Health
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AO/Beck: Good Evening Dr. Dobie. Thanks for spending a little time with me this evening.
Dobie: Happy to do so Doug, thanks for inviting me.
AO/Beck: I've read many of your chapters and articles on medico-legal issues, and I'd like to learn more about your training how you got involved with this area of expertise. Can you give me a little background regarding your position at NIH?
Dobie: Sure. I am a fulltime NIH employee since about a year ago. However, when I first accepted the fulltime position we agreed that I would remain clinically active, so I am seeing patients at the NIH Clinical Center and at the VA Hospital in Washington DC. At NIH, I oversee the extramural research programs associated with the NIDCD (National Institute on Deafness and other Communication Disorders). We manage a 300 million dollar budget and administer the grants related to hearing, taste, smell, balance and other sensory disorders as well as voice, speech and language. At NIH, we divide the world into intra-mural and extra-mural studies. The work done on campus in Bethesda, Maryland is intra-mural; the rest is extra-mural.
AO/Beck: Regarding your training, I know you're an otolaryngologist. In what area do you practice, and can you give me a little information on your residency and fellowship?
Dobie: I limit my practice to otology. My fellowship was in Zurich, Switzerland with Dr. Ugo Fisch and I was there in 1983-1984. I also did a research fellowship with Chuck Berlin in auditory physiology at Kresge in New Orleans. And I went to medical school and did my residency under Blair Simmons M.D. at Stanford.
AO/Beck: Can you tell me how you got interested in medico-legal issues as your area of expertise?
Dobie: My medical school room-mate had a father who was a physician in charge of occupational medicine at Kaiser Aluminum & Chemical corporation. I became a friend of the family through medical school and residency. Then, when I finished my residency, Dr. Hughes asked me to consult for Kaiser on hearing loss issues. Of course I told him I knew almost nothing about occupational hearing loss and he said essentially none of the other ENT guys seemed to know much about it either. So he encouraged me to get involved and learn as I went along, and I did. The more I got involved with it, the more interesting it became. I believe that if you do a good job in hearing conservation and in the medico-legal area, you can do a lot of good for a lot of people because there are millions of people involved. Contrast that to surgery, where you benefit one person at a time, and there is a real win for the patients through professional involvement in occupational causes of hearing loss.
Of course, after I became familiar with the literature and the issues, it was quite natural to get cases where the question would arise as to whether or not a claim was legitimate, or was it poorly founded. I have to admit that at first the medico-legal system and my involvement in it were quite frightening and foreign. Later, it became more comfortable and the issues were interesting and cerebral and it is actually quite entertaining in some respects.
AO/Beck: Was there one particular text or reference that was the primary source of information for you regarding medico-legal issues?
Dobie: No, not really. I've always been more interested in going to the journals and the primary sources of information. There were some books along the way that were helpful, but there wasn't a book out there that I could say was really pivotal.
AO/Beck: Is there any single case you could say was 'the most interesting' case you worked on?
Dobie: No, not really. I have had several fascinating cases and I'd have a hard time picking the single most interesting one. However, I can say that as a group, the railroad cases have been the most interesting. Surprisingly, they're really not about individual claimants. These cases are essentially between the railroads and their insurance companies. The railroads wanted to be reimbursed for the millions of dollars they had paid out to their employees, who had suffered noise induced hearing loss based on their occupational situations. The insurance companies basically claimed they didn't have to pay because the railroads hadn't exhausted their deductibles. It's interesting that most of the railroad companies purchase new insurance policies from a different insurance company every year. It's similar to the consumer who might change their car insurance policy every year from company ABC to company XYZ. Regardless, each policy and each company had their own deductible which could be a half million dollars or perhaps a million dollars and the issue became ...Was the deductible to be applied one case at a time or was it an aggregate situation? So this situation was quite unusual because it wasn't a situation where you had one enormous company against a tiny working person. Rather, it was a situation where you had one giant company against another giant company. The people who retained me said you could take a percentage of the hearing loss and apply it to the employer at a given point in time. In other words, they argued that you could indeed say X percentage occurred in this year and Y percentage of the hearing loss was attributable to that year and that the insurer during the given period of time was responsible only for costs in excess of the deductible for that year. The railroad companies were arguing that it was impossible to estimate how much hearing loss occurred in a particular year, for a given group of workers. They argued that all the occurrences from a particular railroad, across all of the years, constituted a single occurrence, and therefore, only one deductible needed to be satisfied. So, these cases become very complex and very interesting regarding learning how insurance companies and their clients do business.
AO/Beck: What about Worker's Compensation Laws? Where are we on this and what are your thoughts regarding the current state of WC Laws, rules and regs?
Dobie: That's a very timely question because Susan Megerson and I just co-authored a chapter in 'The Noise Manual' on that very subject.
AO/Beck: I have read that chapter and I thought it was comprehensive and very well done. Let me give the reference here because the two of you actually did a state-by-state analysis of the WC laws, and I think that serves as a great starting point and reference for the interested reader. The book is titled THE NOISE MANUAL, Fifth Edition, Edited by Berger, Royster, Royster, Driscoll and Layne, and it is published through the AIHA Press (American Industrial Hygiene Association) in Fairfax, Virginia.
Dobie: Thanks for noting that. Susan Megerson actually did all of the detail work in gathering and organizing that information, and it was a tremendous effort including all fifty states and Canada and other areas as well. The table she put together is truly amazing. In fact, every state ought to have an asterisk after it because each state is different and if you ask two state employees the same question regarding their WC laws, you get two different answers.
AO/Beck: The variation is really tremendous from state-to-state, and as you point out, it also varies within the state based on who is interpreting it. What other issues do you see as pivotal in WC laws relating to hearing loss?
Dobie: My personal opinion is that despite what people think, the awards for hearing loss are actually very low. I think this is one of the important reasons why industry in general doesn't get more involved with hearing loss. There is not much of an incentive for industry to enforce the hearing conservation rules. I don't know this for a fact but I think it's true. Basically, if they slide on hearing conservation, the downstream costs are not that bad and the industries involved may be willing to take a calculated risk. The typical worker in the USA may have a substantial and bothersome hearing loss, but they leave the hearing after a successful WC claim with ten to fifteen thousand dollars, which is basically hearing aid money, and not a great deal more than that. I think that is really striking in many respects.
AO/Beck: So what do we do and where do we go to get better hearing conservation laws and certainly better compliance?
Dobie: I'd like to see OSHA do a few things that I think would be helpful and hopefully, they wouldn't be too controversial. For instance, regarding the Noise Reduction Ratings (NRRs), which is essentially an EPA (Environmental Protection Agency) product, I'd like to see OSHA endorse the standard suggested by the NHCA (National Hearing Conservation Association). Additionally, I'd like to see a regulation published and enforced to cover construction workers. Construction workers are covered somewhat, but they have a separate chapter in the law and although they are under similar guidelines to general industry, there is no application of the Hearing Conservation Amendment, so these folks have much less noise protection. Additionally, Oil and Gas workers aren't covered at all and agriculture isn't covered at all and so there surely is more work to do.
AO/Beck: If it were up to you to decide on WC law changes, what else would you recommend?
Dobie: In the final analysis, if it were up to me, I'd like to see all workers covered in the WC laws. I'd also like to see much larger awards to incentivize corporations to better address hearing protection, hearing conservation and certainly more attention should be focused on enforcement of the current laws. We don't know what percentage of the workers are being well protected in small, medium and large companies, but there is a suspicion that many employers just blow these things off because they can basically get away with it.
AO/Beck: I know we used some of your chapters in our doctoral studies at the University of Florida - any other new books or chapters you would recommend for the interested reader?
Dobie: The second edition of 'MEDICAL-LEGAL EVALUATION OF HEARING LOSS' has just been revised and it should be out by April or May, 2001. I have some excellent co-authors and the book will be published through Singular Publishing, which is now Singular-Thompson Learning. The toll free phone number is 1-800-842-3636.
AO/Beck: Dr. Dobie it has been a pleasure speaking with you. I appreciate your time and expertise.
Dobie: Thanks Doug. It was a pleasure speaking with you too.
Dobie: Happy to do so Doug, thanks for inviting me.
AO/Beck: I've read many of your chapters and articles on medico-legal issues, and I'd like to learn more about your training how you got involved with this area of expertise. Can you give me a little background regarding your position at NIH?
Dobie: Sure. I am a fulltime NIH employee since about a year ago. However, when I first accepted the fulltime position we agreed that I would remain clinically active, so I am seeing patients at the NIH Clinical Center and at the VA Hospital in Washington DC. At NIH, I oversee the extramural research programs associated with the NIDCD (National Institute on Deafness and other Communication Disorders). We manage a 300 million dollar budget and administer the grants related to hearing, taste, smell, balance and other sensory disorders as well as voice, speech and language. At NIH, we divide the world into intra-mural and extra-mural studies. The work done on campus in Bethesda, Maryland is intra-mural; the rest is extra-mural.
AO/Beck: Regarding your training, I know you're an otolaryngologist. In what area do you practice, and can you give me a little information on your residency and fellowship?
Dobie: I limit my practice to otology. My fellowship was in Zurich, Switzerland with Dr. Ugo Fisch and I was there in 1983-1984. I also did a research fellowship with Chuck Berlin in auditory physiology at Kresge in New Orleans. And I went to medical school and did my residency under Blair Simmons M.D. at Stanford.
AO/Beck: Can you tell me how you got interested in medico-legal issues as your area of expertise?
Dobie: My medical school room-mate had a father who was a physician in charge of occupational medicine at Kaiser Aluminum & Chemical corporation. I became a friend of the family through medical school and residency. Then, when I finished my residency, Dr. Hughes asked me to consult for Kaiser on hearing loss issues. Of course I told him I knew almost nothing about occupational hearing loss and he said essentially none of the other ENT guys seemed to know much about it either. So he encouraged me to get involved and learn as I went along, and I did. The more I got involved with it, the more interesting it became. I believe that if you do a good job in hearing conservation and in the medico-legal area, you can do a lot of good for a lot of people because there are millions of people involved. Contrast that to surgery, where you benefit one person at a time, and there is a real win for the patients through professional involvement in occupational causes of hearing loss.
Of course, after I became familiar with the literature and the issues, it was quite natural to get cases where the question would arise as to whether or not a claim was legitimate, or was it poorly founded. I have to admit that at first the medico-legal system and my involvement in it were quite frightening and foreign. Later, it became more comfortable and the issues were interesting and cerebral and it is actually quite entertaining in some respects.
AO/Beck: Was there one particular text or reference that was the primary source of information for you regarding medico-legal issues?
Dobie: No, not really. I've always been more interested in going to the journals and the primary sources of information. There were some books along the way that were helpful, but there wasn't a book out there that I could say was really pivotal.
AO/Beck: Is there any single case you could say was 'the most interesting' case you worked on?
Dobie: No, not really. I have had several fascinating cases and I'd have a hard time picking the single most interesting one. However, I can say that as a group, the railroad cases have been the most interesting. Surprisingly, they're really not about individual claimants. These cases are essentially between the railroads and their insurance companies. The railroads wanted to be reimbursed for the millions of dollars they had paid out to their employees, who had suffered noise induced hearing loss based on their occupational situations. The insurance companies basically claimed they didn't have to pay because the railroads hadn't exhausted their deductibles. It's interesting that most of the railroad companies purchase new insurance policies from a different insurance company every year. It's similar to the consumer who might change their car insurance policy every year from company ABC to company XYZ. Regardless, each policy and each company had their own deductible which could be a half million dollars or perhaps a million dollars and the issue became ...Was the deductible to be applied one case at a time or was it an aggregate situation? So this situation was quite unusual because it wasn't a situation where you had one enormous company against a tiny working person. Rather, it was a situation where you had one giant company against another giant company. The people who retained me said you could take a percentage of the hearing loss and apply it to the employer at a given point in time. In other words, they argued that you could indeed say X percentage occurred in this year and Y percentage of the hearing loss was attributable to that year and that the insurer during the given period of time was responsible only for costs in excess of the deductible for that year. The railroad companies were arguing that it was impossible to estimate how much hearing loss occurred in a particular year, for a given group of workers. They argued that all the occurrences from a particular railroad, across all of the years, constituted a single occurrence, and therefore, only one deductible needed to be satisfied. So, these cases become very complex and very interesting regarding learning how insurance companies and their clients do business.
AO/Beck: What about Worker's Compensation Laws? Where are we on this and what are your thoughts regarding the current state of WC Laws, rules and regs?
Dobie: That's a very timely question because Susan Megerson and I just co-authored a chapter in 'The Noise Manual' on that very subject.
AO/Beck: I have read that chapter and I thought it was comprehensive and very well done. Let me give the reference here because the two of you actually did a state-by-state analysis of the WC laws, and I think that serves as a great starting point and reference for the interested reader. The book is titled THE NOISE MANUAL, Fifth Edition, Edited by Berger, Royster, Royster, Driscoll and Layne, and it is published through the AIHA Press (American Industrial Hygiene Association) in Fairfax, Virginia.
Dobie: Thanks for noting that. Susan Megerson actually did all of the detail work in gathering and organizing that information, and it was a tremendous effort including all fifty states and Canada and other areas as well. The table she put together is truly amazing. In fact, every state ought to have an asterisk after it because each state is different and if you ask two state employees the same question regarding their WC laws, you get two different answers.
AO/Beck: The variation is really tremendous from state-to-state, and as you point out, it also varies within the state based on who is interpreting it. What other issues do you see as pivotal in WC laws relating to hearing loss?
Dobie: My personal opinion is that despite what people think, the awards for hearing loss are actually very low. I think this is one of the important reasons why industry in general doesn't get more involved with hearing loss. There is not much of an incentive for industry to enforce the hearing conservation rules. I don't know this for a fact but I think it's true. Basically, if they slide on hearing conservation, the downstream costs are not that bad and the industries involved may be willing to take a calculated risk. The typical worker in the USA may have a substantial and bothersome hearing loss, but they leave the hearing after a successful WC claim with ten to fifteen thousand dollars, which is basically hearing aid money, and not a great deal more than that. I think that is really striking in many respects.
AO/Beck: So what do we do and where do we go to get better hearing conservation laws and certainly better compliance?
Dobie: I'd like to see OSHA do a few things that I think would be helpful and hopefully, they wouldn't be too controversial. For instance, regarding the Noise Reduction Ratings (NRRs), which is essentially an EPA (Environmental Protection Agency) product, I'd like to see OSHA endorse the standard suggested by the NHCA (National Hearing Conservation Association). Additionally, I'd like to see a regulation published and enforced to cover construction workers. Construction workers are covered somewhat, but they have a separate chapter in the law and although they are under similar guidelines to general industry, there is no application of the Hearing Conservation Amendment, so these folks have much less noise protection. Additionally, Oil and Gas workers aren't covered at all and agriculture isn't covered at all and so there surely is more work to do.
AO/Beck: If it were up to you to decide on WC law changes, what else would you recommend?
Dobie: In the final analysis, if it were up to me, I'd like to see all workers covered in the WC laws. I'd also like to see much larger awards to incentivize corporations to better address hearing protection, hearing conservation and certainly more attention should be focused on enforcement of the current laws. We don't know what percentage of the workers are being well protected in small, medium and large companies, but there is a suspicion that many employers just blow these things off because they can basically get away with it.
AO/Beck: I know we used some of your chapters in our doctoral studies at the University of Florida - any other new books or chapters you would recommend for the interested reader?
Dobie: The second edition of 'MEDICAL-LEGAL EVALUATION OF HEARING LOSS' has just been revised and it should be out by April or May, 2001. I have some excellent co-authors and the book will be published through Singular Publishing, which is now Singular-Thompson Learning. The toll free phone number is 1-800-842-3636.
AO/Beck: Dr. Dobie it has been a pleasure speaking with you. I appreciate your time and expertise.
Dobie: Thanks Doug. It was a pleasure speaking with you too.
Robert Dobie, MD
clinical professor of otolaryngology at both the University of Texas (San Antonio) and the University of California (Davis)
Robert Dobie is clinical professor of otolaryngology at both the University of Texas (San Antonio) and the University of California (Davis). His research interests in recent years have included noise-induced and age-related hearing loss, as well as tinnitus. He is the author of Medical-Legal Evaluation of Hearing Loss (Singular – Thomson Learning, second edition, 2001) as well as over 150 other publications.