Interview with Robert Sandlin, Ph.D.
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Topic: Perspectives in Audiology - 2005
Beck: Hi Bob. It's an honor to spend time with you. Thanks for meeting with me.
Sandlin: Good morning Doug. It's great to see you again.
Beck: Bob, would you please tell me about your education and your professional experiences?
Sandlin: Sure thing. I earned my master's in 1954 and my Ph.D. in 1961. Both degrees were completed at Wayne State University in Detroit, Michigan. In those days one majored in speech pathology with an emphasis on hearing disorders. I was the second graduate student to earn a Ph.D. in 'audiology' from Wayne State. I did my undergraduate studies at San Diego State University where I majored in Speech and Hearing Sciences. I was most fortunate in being offered a scholarship for graduate studies at Wayne State. I completed my masters and most of my doctoral studies before I got my first job as a research audiologist at the San Francisco Hearing and Speech Center, I was there for about one and a half years. While there, I learned a great deal. After the Hearing and Speech Center experience, I was offered an assistant professorship at Arizona State University. I had the pleasure of introducing and developing their audiology program. It was a Spartan effort since money was scarce.
After ASU, I worked in various clinical settings. I was Associate Director of the Speech, Hearing and Neurosensory Center at Children's Hospital in San Diego from 1970 to 1978, which I really enjoyed. We did some early work on ABR with some very bright physicians. Drs. Terry Picton, Kurt Hecox, Bob Galambos and others published some germinal studies on evoked potentials. Dr. Galambos, an internationally known neuroscientist was instrumental in getting government grants. Following my work at Children's' Hospital, I entered private practice.
Beck: I didn't know you had a private practice?
Sandlin: Well, I'm not so sure that was my best decision ever! In those days, audiologists were not recognized very well by the public, or by other professionals, and it was a very different world. I was in private practice for some eight years, sold my practice and then went into consulting.
Beck: When did you start the International Hearing Aid Seminar?
Sandlin: That must've been about 1970. The idea was to bring audiologists and dispensers together to learn from each other and to share knowledge about the auditory system. The conference was well received and it went on for twenty years. During that same time period, Dr Galambos and I started the Seminar on Evoked Potentials, and that series went on for seven years.
Beck: I know you were a member of the Scientific Advisory Board of the American Tinnitus Association (ATA) too. How did you hook up with the ATA?
Sandlin: I think it was early 1976. I had a tinnitus patient and I knew absolutely nothing about tinnitus, so I called Jack Vernon. He suggested I come up to his clinic for a week to learn the diagnosis and treatment protocols. Later on, I served on the ATA Scientific Advisory Board for about twenty years, and retired from it about four years ago.
Beck: Regarding tinnitus, suppose I gave you ten typical tinnitus patients to manage, with normal variation in their type and degree of tinnitus and with typical etiologies such as noise induced hearing loss, presbycusis, ototoxic meds and the like....of those ten...How many can we anticipate will be satisfied with their tinnitus treatment 6 months later?
Sandlin: Excellent question, but unfortunately, you can't anticipate the outcome. I think the first issue is to define "satisfaction." Each patient may have a different idea as to what "satisfaction" is, even though their tinnitus history may be similar to others. I believe acceptance of the clinical program is critical to success. Certainly, Jastreboff's TRT therapy has been beneficial for many people. The program, is based on a neurophysiological model and does include the need for patient acceptance of the treatment program. There are also treating methods based on masking (Vernon) which works for some people, and there are psychological and medical therapies, which work for some. Because tinnitus is so highly variable and individualized, I don't think I can give you a firm number, but many therapeutic programs are tailored to meet individual needs. I think chances are better than even that many patients can show benefit, regardless of the therapeutic approach.
Beck: Very good. What are your thoughts regarding what we have not yet accomplished with hearing aid amplification?
Sandlin: As you know, I have an abiding interest in hearing aids and their application. Frankly, I am very impressed with the current level of digitally based speech processing. DSP in hearing aids constitutes a significant advance in amplification systems. I think we shall see increased efforts to develop technology that improves ones ability to have true binaural hearing. That is, hearing aids that work together to process spectral, amplitude and phase cues. I think there will be continued research on the contribution of directional microphones to improve word recognition in a number of noise backgrounds. Even with all of the technology, I think we still fall short in adequately assessing hearing loss and hearing aid candidacy and use, there's still plenty of work to be done!
Beck: It's sort of Moore's Principle applied to hearing aids. George Moore was one of the founders of Intel. Back in 1965, he said the number of transistors on a chip would double every 24 months...and I guess we can loosely extrapolate that the abilities of hearing aids to process sound has also doubled every 24 months. In fact, I would guess the progress over the last ten years has been virtually unquantifiable.
Sandlin: I agree, changes come at us very quickly Most of them are very positive and they continue to get better - in some instances, even before we've been able to quantify the latest innovation.
Beck: So we're always trying to catch up to a moving target, and the closer we get, the faster it moves away.....quite the dilemma.
Sandlin: Doug, that's true. As a profession, we haven't done as much as I would like regarding documenting the advantages and improvements of modern hearing aids. In part we are using analog reasoning to measure the value of digital technology. I do think we will see good research quantifying hearing aid efficiency, but sometimes, the data gathered is challenged by innovation.
Beck: I guess we're in a somewhat advantageous dilemma? Obviously we'd like to have outcomes studies validating our claims and sciences, but as long as we continue to push the technology forward according to Moore's Principle, we just cannot design the studies and carry them through to fruition and analyze the results in a timely fashion. So I guess pilot studies and Beta tests have to suffice for the time being. What about aural rehabilitation? What should we be doing?
Sandlin: The problem is that audiologists may or may not offer aural rehabilitation because of time or financial constraints. Either way, many patients are not getting AR programs, and that is unfortunate. We know the origins of audiology were firmly planted in AR, and we know AR protocols produce lower return rates and more highly satisfied patients. For some, AR is a financial issue.
Beck: I think that's exactly correct. The issue of offering AR often boils down to finances. The audiologist is essentially unable to charge Medicare or other third party payers for AR, and so it becomes yet another free service if offered, or perhaps it's considered part of the "bundled" costs. So it's another dilemma. We know AR has terrific value, but we also know we need to charge for our professional services and products or we cannot afford to stay in business.
Sandlin: That's it in a nutshell. AR is extremely important and we have to find a way to provide it to every patient. As you noted, it is likely a matter of time and money. Patients become less motivated when money is involved. Some audiologists offer incentives programs to the patient to encourage participation in the AR program; free hearing aid checks, reduced cost for batteries and other enticements that attracts them to the AR program. One idea having merit is to offer an additional 20 or 30 day return period for patients that participate in AR programs. So the bottom line is, there are many creative ways we can provide AR, and hopefully one day we'll be able to charge for our professional time and services too! But in the meantime, the service needs to be available. My feeling is that an AR program should be a standard ingredient in the patient's counseling and management procedures. The type of AR depends on the individual needs of the patient
Beck: Those are all helpful ideas Bob. One thing I like to tell students is that hearing aids help patients hear, but AR helps patients listen.
Sandlin: I like that, and I agree. AR is just too important to dismiss. We just have to offer it to every patient if we expect them to achieve maximum benefit from hearing aid use.
Beck: On a totally different subject, do you think the "30 day trial" works for us or against us?
Sandlin: In many cases it works against us. First of all, it sends a signal that the patient should be doing well by the 30th day. Although that may indeed happen as a general rule, it's an unreasonable assumption. For many people, it takes 30 to 60 and sometimes 90 days or more to plateau and perform maximally with hearing aids. The time needed varies based on the type and degree of hearing loss, age, neural plasticity, adaptation, and other factors too, all of which vary. When we set a mark of 30 days, we may be setting unrealistic expectations and we set ourselves and our patients up for failure. Frankly, my biggest issue is patient management strategies, and I'd like to see more professionals offering AR and counseling. As I mentioned a moment ago, by extending the trial period, we may significantly reduce the number of returns while increasing patient acceptance of amplification and the acquisition of hearing aids.
Beck: Dr. Sandlin, it is a pleasure to spend time with you and thanks so much for sharing your thoughts on these issues. Thanks so much for your time.
Sandlin: Dr. Beck, it's been a joy for me to work with you, too. May I also commend you for creating the benchmark of quality and sustaining Audiology Online?
Beck: Thanks Bob. I appreciate your comment. As you know, the secret to success is surrounding yourself with talented people!
Sandlin: Good morning Doug. It's great to see you again.
Beck: Bob, would you please tell me about your education and your professional experiences?
Sandlin: Sure thing. I earned my master's in 1954 and my Ph.D. in 1961. Both degrees were completed at Wayne State University in Detroit, Michigan. In those days one majored in speech pathology with an emphasis on hearing disorders. I was the second graduate student to earn a Ph.D. in 'audiology' from Wayne State. I did my undergraduate studies at San Diego State University where I majored in Speech and Hearing Sciences. I was most fortunate in being offered a scholarship for graduate studies at Wayne State. I completed my masters and most of my doctoral studies before I got my first job as a research audiologist at the San Francisco Hearing and Speech Center, I was there for about one and a half years. While there, I learned a great deal. After the Hearing and Speech Center experience, I was offered an assistant professorship at Arizona State University. I had the pleasure of introducing and developing their audiology program. It was a Spartan effort since money was scarce.
After ASU, I worked in various clinical settings. I was Associate Director of the Speech, Hearing and Neurosensory Center at Children's Hospital in San Diego from 1970 to 1978, which I really enjoyed. We did some early work on ABR with some very bright physicians. Drs. Terry Picton, Kurt Hecox, Bob Galambos and others published some germinal studies on evoked potentials. Dr. Galambos, an internationally known neuroscientist was instrumental in getting government grants. Following my work at Children's' Hospital, I entered private practice.
Beck: I didn't know you had a private practice?
Sandlin: Well, I'm not so sure that was my best decision ever! In those days, audiologists were not recognized very well by the public, or by other professionals, and it was a very different world. I was in private practice for some eight years, sold my practice and then went into consulting.
Beck: When did you start the International Hearing Aid Seminar?
Sandlin: That must've been about 1970. The idea was to bring audiologists and dispensers together to learn from each other and to share knowledge about the auditory system. The conference was well received and it went on for twenty years. During that same time period, Dr Galambos and I started the Seminar on Evoked Potentials, and that series went on for seven years.
Beck: I know you were a member of the Scientific Advisory Board of the American Tinnitus Association (ATA) too. How did you hook up with the ATA?
Sandlin: I think it was early 1976. I had a tinnitus patient and I knew absolutely nothing about tinnitus, so I called Jack Vernon. He suggested I come up to his clinic for a week to learn the diagnosis and treatment protocols. Later on, I served on the ATA Scientific Advisory Board for about twenty years, and retired from it about four years ago.
Beck: Regarding tinnitus, suppose I gave you ten typical tinnitus patients to manage, with normal variation in their type and degree of tinnitus and with typical etiologies such as noise induced hearing loss, presbycusis, ototoxic meds and the like....of those ten...How many can we anticipate will be satisfied with their tinnitus treatment 6 months later?
Sandlin: Excellent question, but unfortunately, you can't anticipate the outcome. I think the first issue is to define "satisfaction." Each patient may have a different idea as to what "satisfaction" is, even though their tinnitus history may be similar to others. I believe acceptance of the clinical program is critical to success. Certainly, Jastreboff's TRT therapy has been beneficial for many people. The program, is based on a neurophysiological model and does include the need for patient acceptance of the treatment program. There are also treating methods based on masking (Vernon) which works for some people, and there are psychological and medical therapies, which work for some. Because tinnitus is so highly variable and individualized, I don't think I can give you a firm number, but many therapeutic programs are tailored to meet individual needs. I think chances are better than even that many patients can show benefit, regardless of the therapeutic approach.
Beck: Very good. What are your thoughts regarding what we have not yet accomplished with hearing aid amplification?
Sandlin: As you know, I have an abiding interest in hearing aids and their application. Frankly, I am very impressed with the current level of digitally based speech processing. DSP in hearing aids constitutes a significant advance in amplification systems. I think we shall see increased efforts to develop technology that improves ones ability to have true binaural hearing. That is, hearing aids that work together to process spectral, amplitude and phase cues. I think there will be continued research on the contribution of directional microphones to improve word recognition in a number of noise backgrounds. Even with all of the technology, I think we still fall short in adequately assessing hearing loss and hearing aid candidacy and use, there's still plenty of work to be done!
Beck: It's sort of Moore's Principle applied to hearing aids. George Moore was one of the founders of Intel. Back in 1965, he said the number of transistors on a chip would double every 24 months...and I guess we can loosely extrapolate that the abilities of hearing aids to process sound has also doubled every 24 months. In fact, I would guess the progress over the last ten years has been virtually unquantifiable.
Sandlin: I agree, changes come at us very quickly Most of them are very positive and they continue to get better - in some instances, even before we've been able to quantify the latest innovation.
Beck: So we're always trying to catch up to a moving target, and the closer we get, the faster it moves away.....quite the dilemma.
Sandlin: Doug, that's true. As a profession, we haven't done as much as I would like regarding documenting the advantages and improvements of modern hearing aids. In part we are using analog reasoning to measure the value of digital technology. I do think we will see good research quantifying hearing aid efficiency, but sometimes, the data gathered is challenged by innovation.
Beck: I guess we're in a somewhat advantageous dilemma? Obviously we'd like to have outcomes studies validating our claims and sciences, but as long as we continue to push the technology forward according to Moore's Principle, we just cannot design the studies and carry them through to fruition and analyze the results in a timely fashion. So I guess pilot studies and Beta tests have to suffice for the time being. What about aural rehabilitation? What should we be doing?
Sandlin: The problem is that audiologists may or may not offer aural rehabilitation because of time or financial constraints. Either way, many patients are not getting AR programs, and that is unfortunate. We know the origins of audiology were firmly planted in AR, and we know AR protocols produce lower return rates and more highly satisfied patients. For some, AR is a financial issue.
Beck: I think that's exactly correct. The issue of offering AR often boils down to finances. The audiologist is essentially unable to charge Medicare or other third party payers for AR, and so it becomes yet another free service if offered, or perhaps it's considered part of the "bundled" costs. So it's another dilemma. We know AR has terrific value, but we also know we need to charge for our professional services and products or we cannot afford to stay in business.
Sandlin: That's it in a nutshell. AR is extremely important and we have to find a way to provide it to every patient. As you noted, it is likely a matter of time and money. Patients become less motivated when money is involved. Some audiologists offer incentives programs to the patient to encourage participation in the AR program; free hearing aid checks, reduced cost for batteries and other enticements that attracts them to the AR program. One idea having merit is to offer an additional 20 or 30 day return period for patients that participate in AR programs. So the bottom line is, there are many creative ways we can provide AR, and hopefully one day we'll be able to charge for our professional time and services too! But in the meantime, the service needs to be available. My feeling is that an AR program should be a standard ingredient in the patient's counseling and management procedures. The type of AR depends on the individual needs of the patient
Beck: Those are all helpful ideas Bob. One thing I like to tell students is that hearing aids help patients hear, but AR helps patients listen.
Sandlin: I like that, and I agree. AR is just too important to dismiss. We just have to offer it to every patient if we expect them to achieve maximum benefit from hearing aid use.
Beck: On a totally different subject, do you think the "30 day trial" works for us or against us?
Sandlin: In many cases it works against us. First of all, it sends a signal that the patient should be doing well by the 30th day. Although that may indeed happen as a general rule, it's an unreasonable assumption. For many people, it takes 30 to 60 and sometimes 90 days or more to plateau and perform maximally with hearing aids. The time needed varies based on the type and degree of hearing loss, age, neural plasticity, adaptation, and other factors too, all of which vary. When we set a mark of 30 days, we may be setting unrealistic expectations and we set ourselves and our patients up for failure. Frankly, my biggest issue is patient management strategies, and I'd like to see more professionals offering AR and counseling. As I mentioned a moment ago, by extending the trial period, we may significantly reduce the number of returns while increasing patient acceptance of amplification and the acquisition of hearing aids.
Beck: Dr. Sandlin, it is a pleasure to spend time with you and thanks so much for sharing your thoughts on these issues. Thanks so much for your time.
Sandlin: Dr. Beck, it's been a joy for me to work with you, too. May I also commend you for creating the benchmark of quality and sustaining Audiology Online?
Beck: Thanks Bob. I appreciate your comment. As you know, the secret to success is surrounding yourself with talented people!
