Interview with Sergei Kochkin, Ph.D.

Topic: 'Steal Our Stuff!'

Carolyn Smaka: Hello, this is Carolyn Smaka from AudiologyOnline and today I'm speaking with Dr. Sergei Kochkin. Thank you for joining us, Dr. Kochkin.

Dr. Sergei Kochkin: Thanks for having me.

Smaka: My pleasure. I wanted to talk about all the work that the Better Hearing Institute (BHI) (www.betterhearing.org) has been doing promote hearing solutions and hearing care. Can you tell us about some of the latest initiatives?

Kochkin: I think we have to put all of this under an umbrella as what the Better Hearing Institute exists for. We exist to increase traffic into hearing health professional offices. That's it. The question is, why do we do that? Well, for thirty something years we've seen messages saying, "Discover a world of better hearing" and "You should hear what you've been missing" and all kinds of stuff like that. But, there are a number of people whose lives are being affected in a negative way because they have untreated hearing loss. After conducting the NCOA study on hearing aids and quality of life, I've been convinced that providing quality hearing health care is a great way of making a difference in these people's lives. The issue is we've got to provide substantial benefit and communicate that. So, the way I approach it at the Better Hearing Institute through the publications and other means, is by examining the obstacles that stop people from visiting an audiologist or hearing health professional. And we've quantified those in a very meticulous fashion in MarkeTrak VII and another survey coming up that looks at twenty-five year trends in the hearing health industry. So every time BHI embarks on an initiative, it is related to the obstacles that keep a person from entering into the office of an audiologist on Monday morning.

"Two out of three people from MarkeTrak VII indicated that they couldn't afford hearing health care."

Let me give you an example. Two out of three people from MarkeTrak VII indicated that they couldn't afford hearing health care. So we have to ask ourselves, if 2 out of 3 of a total of 24 million people can't afford hearing health care, what are we going to do about it? One solution is the hearing aid tax credit bill. It's one of the biggest and most important initiatives to help people afford our products and services. And I began thinking about how we can possibly reach every senator and representative in America with this information, and that's how we conceived www.hearingaidtaxcredit.org. It is a focused website that deals only with that bill. It makes it very easy for people to make their voices heard on the The Hill. In support of the website, we have a very large e-newsletter database. Through our e-newsletters, we communicated various methods of activism that typical audiologists could do to support the tax credit bill. It's been a few months, and to date we're up to 15,000 letters, which is not bad. To me, and you know me with my big numbers, 15,000 is just a drop in the bucket. We need millions of letters to congress. Just in the couple of months since we've launched the website, more than 20 senators and representatives signed up in support of the bill, so it's going to take a big effort. If I were in practice right now, I would send a postcard to every one of my customers from the last five years and send them to that website. You can see on the BHI website that we've designed such a postcard. I would let all of my patients - every new hearing aid fitting, every audiological testing, you name it - know that this website exists, and make it really easy for them to communicate with their senators and representatives. I'd put www.hearingaidtaxcredit.org on the back of my business card.

Yet while I know through the grapevine who is doing what out there, still quite frankly, I'm disappointed. I think with 25,000 professional stakeholders right now, each should have by now secured at least ten or more letters from their patients. And a lot of professionals aren't doing anything about it, which is kind of shocking to me, because it's a win/win situation for everybody. That's just one of BHI's most recent initiatives.


Smaka: You mentioned that your e-newsletter provides professionals with simple tips that they can implement in their practice to help spread the word about the hearing aid tax credit, and that also promotes their own practice as well. Is that e-newsletter available at BHI's website, www.betterhearing.org?

Kochkin: Yes. You can find these tips on www.betterhearing.org, by going to "Hearing Healthcare Professionals" in the top navigation, and then "Local Public Relations Tools for Hearing Healthcare Professionals." What I'm doing is systematically, adding tools for hearing healthcare professionals to tie their local promotions to our national promotions. There are flyers, articles, an OpEd piece, and much more. I made it so easy for the typical audiologist to get published. And they are getting published. What a great way to advertise a hearing healthcare practice without spending a penny. You just take a professionally written OpEd piece from the Better Hearing Institute, put your name on it and give it to an editor, and you will be shocked as to how many times this stuff is picked up in the media. You know why I know they're getting picked up, because I use a clipping service that tells me.

Visualize it this way, my job is to create positive impressions in the media. Secondly, is to help local professionals to create positive impressions at a local level, piggy-backing on our national stuff, so that's why I write things for them, and I'm thrilled when they get it published.

Smaka: And that taps into the national campaign, like you mentioned. We know the more times people see a message, over and over again, the more it's going to sink in.

Kochkin: At BHI, our mantra is "Steal Our Stuff". We don't want to be an ivory tower. I do what I do because I really want to believe that this is an area where we can impact society.

I need four hours for this interview, Carolyn, I do have a four hour workshop that where we go into some of these things. But basically, for typical audiologists, the best thing they can do is to read MarkeTrak and see the obstacles to hearing care, because the obstacles have to be overcome for consumers to want to come into their offices.

"...half the people who have fairly serious hearing losses as measured in MarkeTrak have never had their hearing professionally tested."

Smaka: Let's talk about some of those obstacles.

Kochkin: Well, half the people who have fairly serious hearing losses as measured in MarkeTrak have never had their hearing professionally tested. Now, we can go out there and run an advertisement that says, for example, "Come and get your hearing tested at XYZ Audiology Services", but let's think outside of the box a little bit. Consumers need to be convinced to come to the professional in the first place, so we need to make it simple. Here's what I did. I created a link, www.hearingcheck.org. This is the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) revised quick hearing check. It consists of 15 subjective questions;it gives a score, and then gives norms for each person as compared to 2300 people with hearing loss. It also tells them what their spouse thinks of them. What's that model based on? It's based on The Great American Health check by the American Cancer Society. So maybe, it's not one of the best things professionals can do to say "go see an audiologist and get your hearing checked", because consumers will ask "why, what for?" Instead, I'd say, "Why don't you go to www.hearingcheck.org, and see if you're at risk for hearing loss or how your hearing compares to people with known hearing loss." Now, I'm trying to validate and predict thresholds and speech discrimination scores with that same test, to give it a greater utility. The reason for this is because we've got a real problem, we've got a lot of people with hearing loss. I'm saying 31 million people with hearing loss, and guess what? The Annals of Internal Medicine just published a study that points to, not 1 in 10 adults in America with hearing loss, but probably closer to 1 in 5, with objective measures.

"The Annals of Internal Medicine just published a study that points to, not 1 in 10 adults in America with hearing loss, but probably closer to 1 in 5, with objective measures."

Smaka: What I really like about the hearing test initiative is that so much of our advertising towards consumers is about technology. But for the people who aren't even getting their hearing tested, those messages about technology certainly aren't going to register.

Kochkin: No, you've got a really good point. I hardly ever talk about technology. We're missing the boat if we just talk technology.

My background is psychology. What we need to do is convince a person that he or she is in pain. And, to a certain extent, I know this may sound cruel. However, our job is to drive people into crisis so that they would want to come and see a hearing healthcare professional in the first place. So how are we doing that? We need to convince people that they're underperforming on the job, therefore, what do I do? I conduct a large study on 44,000 households on the impact of untreated hearing loss on income. Next, we have all these people getting divorced and baby-boomers are dating, so I need to convince them that they're not going to do a very good job on the dating scene. And they're going to be poor partners in intimacy.

You can just go down the list, and go over the entire quality of life issue. People don't get turned on by technology. They get turned on by saying, you know, I've got a problem. So our first job is to get them to recognize they do have a problem. Secondly, we've got to convince them that there's going to be a high probability that when they're coming to see you as a professional, that you're going to solve their problem.

"So the best thing that we can do to promote our practices is to measure benefit and measure satisfaction."

Smaka: And how do you do that?

Kochkin: Now here is where we have a problem, as the entire hearing health industry. Our goal is to convince consumers that the money and effort that they're going to give to us will be more than made up by the changes in their life. To get changes in your life, you need significant benefit. An awful lot of people are cutting corners, and aren't measuring the extent to which hearing aids work. They aren't measuring benefit at all, and aren't communicating benefit. And so if you ask me, what's the number one thing you can do in practice? If I were in practice, first of all I would use the technology out there to make sure that I'm optimizing the amplification of the residual auditory area. We're not doing it. You know I how I know that? Well, minimally a million hearing aids are in the drawer and I'm estimating we solve about 41% of hearing loss out there, if you take benefit divided by the unaided score from something like the APHAB. So the best thing that we can do to promote our practices is to measure benefit and measure satisfaction. Then communicate that to the patient and to the physician since the world is evidence-based. One of the best ways of promoting benefit is just something as simple as our audiogram form. When I look at it, it looks childish. We're supposed to be Au.D.'s and we have, at times, almost infantile looking forms to collect the information. And it's quite embarrassing. This stuff should be computer generated on beautiful paper, and in fact, if someone wants to see an example, on www.betterhearing.org, we have a teaching audiogram. It's in color and on the back is the relationship between hearing loss and quality of life. When we do hearing testing of physicians, which we're going to do shortly at the American Academy of Family Physicians, we use this form. It should be computer generated, and it should be the most scientific professional looking report, for each and every patient, and it's a rare individual that does that. It's the rare individual that measures benefit in quiet and noise, and quite frankly I think a lot of hearing aids are going out the door that aren't working. So, we've got a lot of work to do to improve the consumer journey and it isn't just positive impressions out in the market place.

Smaka: So what you're talking about is really not only talking about bettering the quality of life for consumers, but also looking at the elevating the industry to another level, in order to make the most impact.

Kochkin: I think one of our key strategies is to elevate the importance of hearing in American society. I've said before that hearing is a second rate fence in a visually-oriented world. So to a certain extent, hearing is competing with vision. And so when you think of it, what are we trying to do? We're trying to elevate hearing so it's at least as important as vision. And so BHI's most recent press release and e-newsletters were about the link between diabetes and hearing loss and diabetes and vision loss. And so if you're an audiologist, one of the best things you can do is print that press release and tell people, if you have diabetes, come in and see me for a test. It's a way to get away from just promoting hearing aids and new technology. Now, our job is to promote a better way of life, that we're problem solvers: you ARE going to get a better job;you ARE going to have better relationships;you're GOING to be better off emotionally, psychologically;you're GOING to have a better short term memory. We're also now quoting the Brandeis University study that demonstrated that if you can't hear, you've short-circuited your short term memory functioning.

And this is where we use data like this either for MarkeTrak or from existing studies and piggyback on them to promote the profession.

"The big surprise is, yes, even if you have a mild hearing loss, it's going to impact your income, and it's going to impact you psychologically and socially."

Smaka: Dr. Kochkin, did you see that recent news release about a new study from the Italian journal Acta Otorhinolaryngologica Italica about adults with mild to moderate hearing loss? It concluded that the subjects they studied were having quality of life issues due to their hearing loss. They're suffering more anxiety and having similar problems that you found in the National Council on Aging study.

Kochkin: Actually, that's fantastic. When you really look at the NCOA study published in 2000 in the Hearing Review (it also has a complete literature review), the big shocker to everybody was that it was really the first study that showed that there's almost a linear relationship between degree of hearing loss and quality of life. The big surprise is, yes, even if you have a mild hearing loss, it's going to impact your income, and it's going to impact you psychologically and socially. You might not have the devastating isolation that somebody with severe hearing loss might have, but you're going to have some isolation because you're going to be in environments where you're just not going to quite be part of the communication. Until that point, the issue of advocacy and the hearing health care industry had always focused on the profoundly impaired and deaf. Part of the reason was to prove that cochlear implants were worth the money and stuff like that.

That's one of the best things that we can say is that this quality of life issue, first of all, is it's not benign, and second of all, it's not just something that we can attribute to the top 5% of people with hearing loss in America. It's everyone with hearing loss.

"Out of the independent polls that I've taken whenever I give presentations, I find unanimous agreement that audiologists absolutely provide some form of relief from tinnitus. It may be one of our best kept secrets."

Smaka: Dr. Kochkin, I heard recently about some tinnitus research that you will be shortly undertaking. Can you talk about that?

Kochkin: We always think of things in terms of opportunities. I'm a research based person, so I go back to MarkeTrak, and here's a key finding: 40% of people say they have a hearing loss, but they're not doing anything about it and so I ask why? Because, they say, they also have ringing in the ears. And so the issue and opportunity here is that you may not be able to convince the person that you can do something for the hearing loss until you can demonstrate that you can mitigate or relieve suffering from tinnitus.

Isn't this a natural campaign for audiologists? In fact, it could explode demand for hearing health care in America. This survey is for professionals- for those who haven't taken it, they can take it at www.betterhearing.org/tinnitus. I'm trying to find out what's the state of care out there and from the professional's perspective, are you mitigating tinnitus, and in what way? We've got some new devices out there. We've got maskers;we've got hearing aids. Just wearing hearing aids that are amplified appropriately, are they causing a person to focus less on tinnitus?



I just finished a great book on tinnitus because I'm trying to learn more in this area. It's the Consumer Handbook on Tinnitus edited by Dr. Richard Tyler (available from Auricle Ink Publishers). It's kind of a gestalt concept, that if we can take that annoying tinnitus, which is being focused on by a certain area of the brain, from the foreground and put it appropriately into the environment, then we can give the person amplification for their hearing loss. And at the same time, can we reduce the stress and the annoyance that they might have about their tinnitus. It's an interesting concept there. But now we've got to prove efficacy.

The first thing I've done is ask professionals how things are going with the current technology and what are they doing in terms of treatment. Once I tally these results, I'll probably issue a press release. Out of the independent polls that I've taken whenever I give presentations, I find unanimous agreement that audiologists absolutely provide some form of relief from tinnitus. It may be one of our best kept secrets. And so I'm going to reveal this secret. We're going to actually measure customer satisfaction with some of the tinnitus technology, such as hearing aids or maskers. This newest one, that I listened to the other day, features kind of cool music with white noise in the background, and supposedly works on the limbic system to reduce the reaction to the pain and suffering that comes from tinnitus. So, if we really do provide some form of benefit in that area, then my goal is to let the American public know. Then let those professionals who specialize in this area promote at a local level things that we report at a national level. It's a big opportunity.

Smaka: It certainly is and I think there's a lot of misinformation out there. I know when I was in the clinic, patients would always think that somehow hearing aids would make their tinnitus worse, when often times we know it's quite the opposite.

Kochkin: I just visited Dr. Paula Schwartz, who has a wonderful tinnitus clinic in Minneapolis, last week. I heard kind of an interesting statement that tinnitus is the brain's response to auditory deprivation. Isn't that kind of cool?

Smaka: Yes, very cool.

Kochkin: And so, our goal is to not create unrealistic expectations, but to tell people in an appropriate fashion what other people report, whatever the results are. I'm going to try to measure the percent reduction in tinnitus. That's my goal, always is. The percent improvement in hearing disability or the percent reduction in tinnitus, and that can be done when you really think of it. Aided minus aided, which is benefit, divided by the original unaided problem, gives you the percentage reduction in a particular problem. That's if the inventory is stated in the proper way. Then, for example, I'd say three out of four people say they got some benefit, or one out of four significant benefit, and let the PR move ahead based on the facts, because it's a big issue.

You know what I just realized in the last week, is that we've got a big disjoint between awareness of hearing loss, subjectively, versus the actual incidence of hearing loss as measured. For instance, I say 31 million people with hearing loss in the U.S., but the objective data is saying probably closer to 60 million. And so why do more people Google on tinnitus than hearing loss? Because hearing loss you may not be aware of, especially if it's mild, but with tinnitus you are aware of it because you've got nagging ringing or buzzing in your ears, or in severe cases, the feeling that a subway is going through your brain. So that's why I have a feeling that we're going to find a higher prevalence of tinnitus than we will of hearing loss, it's just a gut feeling of mine.

Smaka: Can we switch gears and talk about your latest fascinating study that had to do with pediatrics?



Kochkin: Yes. This was, I think, the first time in MarkeTrak where I had the co-authors, because pediatrics is not my specialty: Dr. William Luxford from the Hough Ear Clinic, Anne Marie Tharpe, Jerry Northern, and Pam Mason from ASHA - really good people. After looking at years of MarkeTrak, I asked myself, "how come only 12% of kids with hearing loss have hearing aids?" So we did a study and the title of that study, which is in the MarkeTrak series and can be found under "Publications" on the BHI website, is "Are 1 million dependents with hearing loss in America being left behind?" And yes, at times I will do provocative titles like that because I want to get the media interested. This is one of the few MarkeTraks, other than "Why my hearing aids are in the drawer?," where it's almost all letters from parents. And when you look at the recent research published in pediatrics in the Journal of the American Medical Association, and then you look at these parents' responses to MarkeTrak, we've got potentially a real large problem with respect to the pediatric population.

Smaka: In what way?

Kochkin: Let me just mention a couple of things. First of all, we have what I call this tragic triumph of universal newborn screening. Why is it a tragic triumph? Well, because historically 50% of the children never receive follow-up. The infrastructure does not exist for follow-up services to track kids and give them the follow-up services that they need. Or, it does in some localities, but not in others. So, an infant fails, and the audiologist says to the parent, "Looks like there are some problems with your child's hearing. I'd like you to come back in 3 to 4 weeks for more extensive testing." And many times, they don't see the parent until the child is three years of age and the child's already got language problems.

Now, the issue is, "Whose fault? What went wrong?" If I was in practice, say a hospital setting, and I'd conducted an infant screening and I don't hear from the parent in a month, what do you think I'm going to do? I'm going to phone them. I'm going to call them up. Now, people might get a little squeamish when I say this, but if I don't get a return and they don't come back, I don't know whose fault it is and it's something we've got to figure out. But you know what I would do? I'd file a neglect petition in juvenile court, because for me, it's neglect, potentially. In other places from what I'm hearing, it might be misinformation.

I personally believe we've got a mess here, ok? And so, what I'm proposing for the field of audiology is significant advocacy. When an infant fails and you haven't heard something, something has got to be put in place to allow that child optimum access to communication. Because it's going to affect performance in school, language acquisition, cognitive development, social/emotional well-being, academic competence, and guess what, ultimately their development as a productive citizen. Strong evidence suggests that parents are stigmatized by the kid's hearing loss;well, should stigma ever be a reason for denying service to a child? There's strong evidence that pediatricians don't have expertise in this area and should not be the caregivers to the parent. There's strong evidence of a real disjoint in awareness of children's hearing loss, let me give you one example. In MarkeTrak, we show a 1.7% incidence in hearing loss among children, almost exactly equal to the National Institute of Health's data for the last 30 years. What did we find out in an objective study, a health study where 5000 kids were tested? Close to a 15% incidence. 12% incidence of early indications of noise induced hearing loss. What does that mean? This is one of our questions: to what extent do we have adequate screening for children where we can even identify them? And maybe they're not hyperactive, or maybe their not introverted, maybe they just can't hear very well. Even a 25 dB loss to a child is devastating, especially in the classroom, and yet the parent might not recognize it.

Smaka: So you're talking about universal screening and universal follow-up.



Kochkin: And, the only way we can expect parents to know that their school age child has a hearing loss is through school-aged screenings.

The other issue here is appropriate referral. Whose appropriate referral? Well, you know, we need to get to the point where the audiologist gives the advice about hearing loss. We must get away from, "your kid has a hearing loss, he'll get used to it. Sit 'em in the front row." That's what we found. The number one intervention for kids with hearing loss - seat them in the front row. If your child has mild hearing loss, the recommendation is "oh, no big deal, he'll get used to it." Your child has hearing loss in one ear: "oh, favor the other ear when in school. You know, hearing aids aren't worth it, the kid will be stigmatized more." And guess who the victims are, these children.

"There is a tragedy going on with regard to hundreds of thousands of children in America and we've got to become their advocates."

Smaka: It sounds like minimization of the hearing loss.

Kochkin: Massive minimization. I have parents that say "my child can't hear my voice across the room without visual cues." This is from the Gallaudet Scale, and oh by the way, he or she has a very mild hearing loss. Or "my child has a very mild hearing loss, but has been in speech therapy for three years." And then obviously we have the issue of prevention or protection of the hearing of America's children from iPods and noise. My point is we say 1 million dependents in America being left behind;I bet you the figure's about five million, when you take a look at the objective data.

So, I think we've got a lot of work to do with children, and America, as wealthy as we are, there should be no child left behind, financially. And if IDEA legislation is requiring the parent, for instance to prove that their hearing loss, that child's "mild or slightly moderate, or unilateral" hearing loss is a disability or is a major disability, how many hoops are we making parents go through? If a child needs hearing aids, we gotta get hearing aids for that child. We're going to have an underperforming American citizen, a victim, an individual with no self-esteem, and psychological well-being that is damaged beyond repair. There is a tragedy going on with regard to hundreds of thousands of children in America and we've got to become their advocates.

Smaka: It's wonderful to see all the work that BHI has done, tirelessly, to raise awareness of this issue. Dr. Kochkin, what upcoming meetings are on your schedule where professionals may be able to go and catch you presenting your data?

Kochkin: Well, I've presented about thirty times on MarkeTrak VII and now I'm giving to give my last two presentations of the year. One will be at the Maryland Academy of Audiology in September and the other at the International Hearing Society meeting. I have a few more early next year at state meetings, but then I'm putting MarkeTrak VII to bed and moving on to new research areas. All of them based on obstacles to people seeking out hearing solutions earlier in their life.

Smaka: Excellent. With everything you have going on, I really appreciate you taking the time for AudiologyOnline today. I urge professionals to visit www.betterhearing.org. The site is constantly being updated - I'm there weekly and there are always new items to check out such as the tinnitus survey, getting on board with the hearing aid tax credit.org, if you haven't already, and much more. And of course we're all staying tuned for MarkeTrak VIII.

Thank you for all you do, Dr. Kochkin, and for your time today.

Kochkin: Thank you, Carolyn.