Jack of All Trades, Master of One.

Today's episode highlights the importance of becoming experts within a specialty profession. Audiology itself is a specialized profession - vestibular audiology even more so. As young professionals entering an ever changing field, we really need to be the generation to advocate for our profession, showcase our professional utilities, and make our presence a valuable one by filling the void that there is in healthcare.. but first we need to earn our place. 

Transcript

Welcome back everyone and thank you for joining us once again. Clayton here, and im one of your hosts today along with Paxton and Christina. Today's episode highlights the importance of specialty professions. Audiology itself is a specialized profession.. vestibular audiology even more so. In fact, this is one of the main reasons we decided to create this podcast. As young professionals entering an ever changing field, we really need to be the generation to advocate for our profession, specialize our professional utilities, and make our presence a valuable one by filling the void that there is in healthcare.. but first we need to earn our place. We really need to showcase that we know what were talking about and that we are the true specialists of the ear and everything that goes along with it. Now, some of those things may fall outside of our professional wheelhouse, but becoming familiar with different realms of healthcare, such as neurology otolaryngology physical therapy and a lot of things that primary care physicians deal with day-to-day, is an essential aspect of caring for dizzy patients. Because, while we are specialists of the ear, we still need to view our patients as a whole person.

Claiming equilibrium as a specialty, which naturally involves the interconnection and communication between multiple systems, comes with responsibility we need to understand that population inside out as they may be experiencing dizziness as secondary or even a co-existing condition.

If you look at the word ‘specializing’ it is ironic that in infers that we are narrowing our patient population… because actually what I found when weve been here is that it opens our patient population of two disorders outside the air like you're saying, Paxton. Because of the nature of dizziness and equilibrium involving multiple systems such as the visual system, the vestibular system, and the proprioceptive system.. each of these systems are susceptible to disorders on their own so its our job to own the space of knowing that each of the system may be affected by different disorders. If we expect doctors to refer to and rely on us to assess and manage the the patient, it is our responsibility to know as much as we can about the disorders we will be working with. 

That’s exactly right Christina. One really good example of that area that we still are providers should grow further into diabetes health. we should be well established and known within the Diabetes Association to provide them access to help when theyre ready for it.

Diabetes is a great example, but we also assess and manage patients with a wide variety of disorders including: dementia, Parkinson's, cardiovascular disease, you have the patients with osteopenia or osteoporosis (being that they have hypovitaminosis D) we also have our Meniere’s patients, our perilymphatic fistula patients, patients with concussion or migraineurs, and much much more. Somehow all these patients ended up in our offices. They all present differently and their plans of care are all drastically different. So we have to understand how these disorders affect dizziness and balance before we can call ourselves specialists. 

So, lets elaborate a little further on some of these.. Take diabetes, for example. Why should vestibular providers be invested in patients with diabetes? What things should we be keeping on our radar, and how can we best serve this specific population and the providers that may have referred them to us?

Great question. Diabetes affects the eyes, the ears, and our sense of touch in our legs.  If their primary complaint is imbalance, but they aren't experiencing changes to their vision and their vestibular function is robust we may need to refer them elsewhere to address the possibility of peripheral neuropathy. But we can go further than that - We can perform a monofilament screening so when we make that referral, it is backed with suggestive evidence to support the patient reports of their inability to feel their sense of touch on the bottom of their feet and toes. 

that's a really perfect example of how you can go beyond what is expected of you, step a little bit outside of your wheelhouse to provide some value within the field of healthcare. We should ourselves and healers and approach our patients with integrity and purpose. Maybe we should be normalizing specialty certificates in our field in order to demonstrate our ability to perform useful services. If we're going to claim this space and promote our profession as inner ear specialists, then there needs to be a standardized level of care. We can't just have anyone out there doing calorics or VNGs and not really even knowing what they're looking at. 

So, to ensure that AIB offers 6 certification courses for specialty professions. We offer courses on vestibular rehab 1 & 2, vestibular assessment and management 1 & 2, concussion, and pain management.  Ensuring care for dizzy patients makes us a valuable resource for the medical community which we rely on our referrals for. More than knowing what to do it the patient we also have to know how to converse and collaborate with a lot of MDs, PTs, neurologists etc. it is important to know how to maintain relationships and keep them happy. Just like Paxton said earlier, providing a simple screening that's within their realm and can give them some suggestive evidence and that we know everything that comes along with being an imbalanced patient really goes a long way with other professions and really when you think of, it not only goes a long way but it's essential to having a dizzy practice. Seeing dizzy patients is a lot different than seeing hearing patients. We will talk about this in a later episode but part of the business model in marketing is to not market to patients the way that hearing practices market to patients. Actually it is more beneficial for us to market to physicians. 

Patient acquisition is one of those aspects  of practice where there is definitely a stark difference between the realities of the dizzy world vs the hearing world. But since we are going to have an entire episode coming up here shortly that dives deeper into topics of business and dizzy practice management, lets talk a little bit more about practical realities. We obviously need referrals from other physicians and we need them to trust in our abilities. How do we go about establishing and maintaining these relationships to keep them in our corner?

So one critical aspect of maintaining professional collaboration and relationships is be ready to answer questions. If a physician asks you “well how exactly do you intend on helping these patients?” you have to have a good answer. You also need to be able to defend your recommendations and provide resources from the literature that supports your diagnosis and your treatment plan. That's what we would have been trained to do all through grad school. So be ready to keep up with the research and ensure were  using the most up-to-date evidence-based practices. A perfect example of this is that we often will recommend patients monitor vitamin D levels to prophylactically prevent BPPV recurrence. In fact, 70% of Floridians are vitamin D deficient. And vitamin D is not typically found on a common blood pannel for their regular checkups.

Now, why should we care about vitamin D?

What we know is that having low vitamin D in our endolymphatic fluid prevents the efficiency of our body's ability to absorb the calcium carbonate crystals, or otoconia, that fall out of place causing BPPV. This is particularly important for patients with osteoporosis or osteopenia.. Many times other clinicians are actually relying on you, the specialist, to frame hypoitaminosis D from the perspective of our clinical expertise. So for example, the generally accepted normal range for vitamin D levels is bout 30-100. It's our job to inform other physicians that aren't in this area of specialty that when patients recurrent BPPV, what we're looking for is levels to be 50 or higher.

Other than BPPV, migraine is a really big one. As the number one non-otologic cause of vertigo, it affects 13% or more of the adult population in the US. And 50% of all migraineurs deny a physician diagnosis. This is a huge area of need for us to fill because not only is dizziness one of the manifestations of migraine, but our understanding of the physiologic migraine pathways and how they present in patients has come tremendously far in the last 10 or even five years. When patients present with photophobia, photophobia, internal motion, motion intolerance, visual auras etc. we need to be tuned into these things. We need to ask the right questions and be able to counsel on all of these different symptoms that may technically be outside of out wheelhouse. As migraine is a diagnosis of exclusion, your testing is a essential in ruling in or out other possible sources of dizziness, which brings the patient into your door and one step closer to finally getting the answers and the relief that it seeked for so long. Another hot area and research that is common extremely long way in recent years is concussion. If you’ve played sports when you were younger and you've ever known anyone on your team that suffered from a concussion you may remember the different classification grades a concussion that typically had to do with: if you lost consciousness after the impact, how long you lost consciousness, how long you felt symptomatic, if you were vomiting..  but in 2013 the American Academy of neurology published revised guidelines that no longer use concussion grading and instead they emphasized a more detailed neurologic assessment prior to return to play. The tricky part about concussion is that not only does it involve structural and metabolic disturbance to the central nervous system following an impact, but it can also result in inner ear damage and even more frequently BPPV. If someone doesn't necessarily recognize they have suffered from a concussion and they come to you for BPPV treatment, you better be able to look a little bit deeper about concussive symptoms in order to best serve your patients and get into the right doctors in the right therapies. It would be a shame if you only focused on treating BPPV when they tell you they're having sleep disturbances, changes in their mood, changes in their stress levels, they can't read a book anymore, it looks like words are falling off the page. These are all things that should throw up huge red flags when they talk about head impact and when you're looking at postconcussive patients. 

And these are just a few there are many other disorders to talk about.. Ramsey hunt syndrome, herpes zoster oticus, perilymphatic fistula, ototoxicity from aminoglycosides or solvents,  MDDS, and lots lots more. The point they want to make for all of them is: when we come to the table with more to offer than our tests and our equipment we offer more utility than ever before and we become a more welcomed and sought after colleague within the world of healthcare. Referral sources would value our relationship more, utilize extensively, and trust us with their patients.

Okay so I think that was a really great discussion as we are ramping up to prepare for our first guest here on Turning Heads. We are incredibly excited to have this very special guest in the studio with us today. Ladies and gentleman, he is the Founder and Executive Director of The American Institute of Balance. For over 20 years he has been a leader in the development of vestibular evaluation and rehabilitation techniques. He is the author of multiple textbook chapters ranging from diagnostic vestibular testing, vestibular rehabilitation, BPPV treatments and pediatric vestibular evaluation.He was an active member of the board of the American Academy of Audiology for many years, and even served as AAA President. He is the reason we are all here and he is the reason this podcast was made possible. So thank you and welcome: Dr. Richard Gans. 

Oh, thank you very much Clayton, it is a pleasure to be with you. And I want to congratulate you Christina, Paxton, and Courtney on your first podcast episode. It was very impressive.

Thank you very much. So especially in a time like now considering everything that's going on with COVID19 and the state of the world, we are being challenged by the changing of times. As someone been at the top of our field for many years what advice you give to our listeners just entering the world of audiology and other allied health professions?

Well it's a great question Christina I think the most important thing is to not let people put your blocks not let people to set boundaries for you that are really limitations in their own mind. One of the most important things to do is always make sure that your testing your own belief lids. You know our scope of practice in audiology is very very wide and deep. I had the good fortune to be leadership positions for our organization for a number of years actually was involved in writing the scope of practice for the American Academy of audiology also as being a reviewer for the ASHA guidelines as well and the reality of it is that when you read our scope of practice it's enormous and I would urge young audiology students young audiology professionals to step away from the ear and this is something that you as residents have heard me say. In other words, we have to think about the brain. we have to think about human equilibrium. The ear is more than just a place to stick a hearing aid. And I think we do ourselves a great disservice when we don't think about the role of the auditory vestibular system in individuals who are cancer survivors, diabetics, Parkinson's disease, migraine, or pediatrics. So look at everything that's available and don't let other people put you in a pigeonholed position.

You are also well connected globally with various health professionals and assisting them develop vestibular practices with various healthcare models. From your experience, does one healthcare system push for interdisciplinary more than others and if so how can we use what these other systems have developed to benefit patient care here?

That's a very good question Paxton, ive been very fortune in over the last 25 years to be in about 30 different countries so from Kuwait to Argentina to Hong Kong to China many countries in South America, the UK, Canada, and of course here in the United States. The main thing is that you can't fit a square peg in a round hole meaning that when you look at a health system in a country, it also reflects the general belief system, the culture. and whether really, you believe that healthcare is a privilege or a right. We have the best healthcare system in the world but the reality of it is, is that not everybody has access to it. That's why for 28 years, no child has ever been turned away from AIB. Right? if a parent doesn't have insurance will see their children. And this is one of the things that I think is important. I think what we do as audiologists, in particular, whether it's from the cradle to grave - our patients need us and restricting access to us because of their ability to pay of course is one of the greatest challenges. So I always enjoy going to countries where healthcare is right because it's not motivated -- the practitioners want to do the right thing, they want to help their patients they want to help the citizens of their community, and I think that's a beautiful thing..

so obviously you have impacted our field greatly not only as a clinician and author and a researcher but also as the president of AAA for many years what vision you have for our profession and what can we do as young professionals to get there?

Christina thank you for asking the question because one of my favorite sayings is a leader knows the way goes away then shows one of the things that I would encourage all your professionals to do is to find mentors find mentors that they can respect people that don't just talk the talk but walkable I then look at mom's that you could see yourself being in 15 or 20 years is this the kind of professional that you would want to that's one of the greatest things because you know technology changes in technology changes so quickly you know there were people that believed the car would never replace the horse there were people that had typewriter repair businesses that believe that you always need typewriters to type labels although this I when CDs came replace a track and process all this is this is a game changer so we have to be careful that is audiologist we do not worship at the altar all of technology along that we consistently recognize that we have to be lifelong learners and that the real power of being an audiologist is not of the VNG system it's not chair it's not a sound booth it's watching your brain feed your brain and you will have an amazing career.

And there you have it, coming to you straight from the man, the myth, the legend.. Dr. Richard Gans. Thank you so much for being here and spending your time with us. It is always a rewarding experience to learn from you and we are just so grateful for the opportunity to share a little bit of that experience and wisdom with our viewers.

Well thank you, I want to give props to Christina Paxton and Courtney and Clayton for taking on this podcast. I know it means a great deal to AuD students and also young audiology professionals. So I salute you, and I expect to hear great things from all four of you.

Thank you. 

Speaking of the turning heads podcast, we have a lot of really exciting topics coming up here shortly with some more special guests. Topics that focus on interdisciplinary, the business aspect of things, professionalism, having a healer mentality, and much more. Dont forget to reach out to us on social media, on instagram @turningheadspodcast and on facebook at the AIB residents corner. Thanks for tuning in and we hope to hear from you soon!   

FOTD:

Alright everyone, Fact of the day: Ramsey syndrome, herpes zoster oticus, or shingles, are most common in individuals over the age of 50. This viral attack on the ear is related to vestibular neuritis and, when left untreated, is a common cause of dizziness.