The American Institute of Balance with Richard Gans, PhD

Ever wonder how your hearing and balance play a significant role in preventing falls, especially for older adults? Our latest podcast episode brings you an enlightening conversation with Dr. Richard Gans, a global authority on hearing and balance. A personal journey driven by his mother's struggle with intractable Meniere’s disease led him to audiology and shaped his commitment to understanding and treating vertigo. He reflects on the early days of Auditory Brainstem Response (ABR) and Electrocochleography (ECOG), while emphasizing his drive and desire to earn his PhD.

As we mark Fall Prevention Awareness Week, we delve deeper into the labyrinth of the audio-vestibular system. This complex network, akin to a duplex, comprises of the cochlea, or the flat, and the vestibular system, or the townhouse. Dr. Gans shares his transition from retail to a medical model in his practice, highlighting the importance of healthcare providers to stay relevant. As we round up our conversation, we underscore the imperative of collaborative healthcare and discuss patient validation and take inspiration from the optometry model that exemplifies team-based care. Tune in for an insightful discourse on the correlation between hearing-balance and fall prevention!

Link to the full transcript. 

Transcript

SPEAKER_01 0:01

Welcome to Starkey Soundbites. I'm your host, Dave Fabry, Starkey's Chief Innovation Officer. Now it's the fall of the year, it's September, and we know that means like back to school. It means NFL football. And as a co-owner of the Green Bay Packers, I think this year they're going to surprise a few people. And it also may come as a surprise to people that there's a strong connection between falls in the aging population, and it's one of the leading causes of death in the aging population. And so it's with great pleasure that I have a good friend, Dr. Richard Gans, and a global expert in the area of hearing and balance on the call today to talk about fall prevention awareness week. I mean, at Starkey, we think that a fall is already too late, and we really want to avoid a fall whenever possible. But uh it's no coincidence that fall prevention week occurs just prior to the first day of fall. So, Richard, you know, it it's you know, we go back a long way. We were friends in the previous millennium, uh, which ages me more than you. You've held up much better. But uh but it's a pleasure to have you on the podcast.

SPEAKER_00 1:16

Well, thank you. And yeah, we've been friends for like 25 years.

SPEAKER_01 1:20

We have indeed. Uh early days of uh of of AAA, and we were on the board together, and um and now here we are. And uh and here we are with Fall Prevention Week. It is September 18th through the 22nd. I know this is a topic very near and dear to your heart. It's really uh your passion, and you you've been such a strong proponent of focusing, I think, for the audiologist. Now, most of the Soundbite's listeners are hearing care professionals. Um, there are some patients that listen, but um you've uh reminded me for many years that we have to talk about hearing and balance within the scope of practice for audiologists. And why is that so important? Why is it that you really have built your career around raising awareness for the importance of balance as it relates to falls, as it relates to the hearing and balance mechanism? Why is that so important? And what first really drew your interest in that area rather than diagnostics or hearing aids or electrophys?

SPEAKER_00 2:25

Well, actually, electrophys is a strong part of it because we're using APR, we're doing ECOGs, OVEMP, CVEMP, Rotary Chair.

SPEAKER_01 2:35

You've got all the best acronyms.

SPEAKER_00 2:37

Yes. Yes. So it's it you can't talk about balance without neurodiagnostics and electrophysiology. Um my mother was my first professor. So uh I became a student of audiovestibular disorders at about age five because my mother had intractable menirus disease. And so from the time she was about 32 to the time she was 40, she really lost a lot of the best years of an active lifestyle to um vertigo.

SPEAKER_01 3:21

So her primary present in presenting symptoms when she was between 32 and 40 was primarily vestibular rather than audio, or was it both?

SPEAKER_00 3:32

Yes, yes. So she was the classic pre-do. Yeah, right? She knew when the when it was coming. Uh, and in fact, I was an only child. So it was the 1950s, right? My dad's working. We owned uh, like in those days, it was called a package store, you know, liquor, groceries in a little town called Newport, Rhode Island. And my mother knew that the storm was coming, ears would feel full, start to have the tinnitus, and we would prepare, like getting ready for a hurricane. She would get her, we'd get the ice, we'd get the smelling salts, not because she was going to pass out, but my mother intuitively knew about sensory integration. So balance is the sixth sense, right? Yeah, five cents is in balance. But when you have vertigo, there's only two ways to get rid of it time or drugs. So what you would do with sensory integration is if I can't get rid of this, I will raise all of these. Because the brain can only attend to the most noxious stimuli. So smelling salt, strong olefactory, ice, right? Proprioceptive, kinesthetic, and she would lay on the floor and you hold on to the legs of a table. And that gives you that proprioceptive, somatosensory grounding. So I knew as a five and six-year-old, what working with my mom through this, that if we increase these other sensory modalities, the vertigo wouldn't stop. But the what's called the vestibuloautonomic nervous system calmed down. That's diaphoresis, sweating, nausea, and emesis, also known as the woman, right? And so, and then my father, years he had otosclerosis. So between my father with bilateral otosclerosis, you were destined to become an audiologist at a young age. You know, and so I start out, and it was in the early days, we're just hearing about ABR and ECOG. Well, I had already been a practicing audiologist. I said, you know what? I gotta go get a PhD, right? Because a master's degree, I don't know what I need to know. I gotta go get me one of those pilot higher and deeper degrees. So I heard about this little place in Ohio called the Ohio State. And at the Ohio State, all the top people in the world were there at that time. John Ferraro, um Chuck Stockwell, Derek Dunn, um, David Lim, uh Herb Boyer. So, I mean, it was mecha. So I went there to do animal research, learn electrophysiology, and basically never looked back.

SPEAKER_01 7:01

And so after finishing your PhD, what was next in line? Where was your where was your first yeah?

SPEAKER_00 7:10

My best friend was getting a PhD from another very good school of the Big Ten called Purdue. And we decided we would go into practice together. He would specialize in hearing and hearing aids, and I would specialize in uh VD patients. Vegan Dizzy. Yes, yeah, so we opened up in Miami.

SPEAKER_01 7:36

Or vestibular dysfunction patients, thank you.

SPEAKER_00 7:39

No, the Vegan Dizzy. And we opened up uh 13 clinics. We were the largest private practice in the United States. We had 13 clinics from uh West Palm Beach down into the Keys. Then we actually sold to, in those days, it was called Herex, which is now, I guess, here USA. So we sold. Um, Alan went to law school. He became a nationally famous employment law attorney. We're still best friends, and he still handles uh all of my employment law issues. I stayed on with the company for about a year and a half or two years uh as their VP of Whoopti Doo. I um I decided that I better go back out on my own. And in 1992, we moved to the West Coast of Florida and we opened up the American Institute of Balance.

SPEAKER_01 8:38

30 31 years ago.

SPEAKER_00 8:40

31 years ago. It was I it was my capstone for elementary school. Of course, that's how I was able to get into middle school at such an early age.

SPEAKER_01 8:52

You were in one of the highest regarded middle schools in the country, if I'm not mistaken.

SPEAKER_00 8:57

I was bleaker junior high school, uh right near the Whitestone Bridge in Queens.

SPEAKER_01 9:03

Yes, and so so 31 years later, um, would you have changed anything if you knew then what you know now?

SPEAKER_00 9:12

Oh, absolutely.

SPEAKER_01 9:14

Okay, give me to wit. Give me an example.

SPEAKER_00 9:18

Um, well, it's it's anything. You know, hindsight is 2020.

SPEAKER_01 9:22

Sure.

SPEAKER_00 9:23

I would have um I think learned not to be afraid earlier in my youth.

SPEAKER_01 9:35

Well, and I think some of that comes from the PhD training where you're taught to constantly question whether the approach that you've taken is the correct one. And and it does tend to sometimes become a personality attribute of those of us who've gone through PhD programs.

SPEAKER_00 9:49

And then at the point you go, you know what? Uh and I've taught them both my kids happen to be attorneys, but I basically taught them heart of a lion, heart of a lion. If you're gonna live your life in fear of anything, it's no way to live.

SPEAKER_02 10:08

Yeah.

SPEAKER_00 10:08

Oh, what about OTCs? What about oh, this one and that one? Everybody's trying to steal, everybody who moved my cheese, right? What's going on? Um, everybody's out there to do something bad to me. And the late Bob Oliveria, who was quite brilliant from Comply, remember Bob? I know him well. And I used to say to him, Bob, what's the secret? Focus, focus, focus. That's what he always did. He always said it like that. Focus, focus, focus.

SPEAKER_01 10:43

Well, and that really characterizes, I think, what you've been able to accomplish for 31 years by following that advice and really focusing on vestibular and and and dizzy patience within the overall uh hearing and balance portfolio.

SPEAKER_00 11:01

And I learned to open my arms to everyone. I'm a life member of NSHA, I'm a life member of AAA. We have a huge corporate membership with ADA. I'm a research scientist member of AAO in head and neck surgery, I'm a research scientist member of the American Academy of Neurology. I open my arms to everyone because the old saying, Dave, as you know, if you're the smartest one in the room, yeah, you're in the wrong room. So this idea that as an H I S, an audiologist, an M D, a D O, an M-O-U-S E, whatever you think you are, you're not.

SPEAKER_01 11:48

Right. So let's dive in on that a little more then. So with uh the the fall prevention week, what is it that you see is should be the focus during this week that hearing care providers, as you said, uh physicians, audiologists, hearing instant specialists, what should they be considering? It falls within Healthy Aging Month in September. Absolutely.

SPEAKER_00 12:14

And let me talk about that listeners. While I was building up the largest medical audiology practice in America in the 80s, guess what else? Ken Dahlberg was a friend of mine. I had one of the first miracle franchises in the country. I also operated hearing aid dispensing out of six Macy stores in South Florida, out of the optical department. Everybody has a role to play. Everybody. Because if you're seeing older adults, gravity always works, gravity always wins. Right? And remember, it's the audio vestibular system. What I like to talk about is the cochlea and your vestibular system is like a duplex. The cochlea is a flat, it's a rather simple place. The vestibular system attached to it is like a townhouse. You have downstairs, you have upstairs. Downstairs is the odolith system, that's your gravity detector. Upstairs, you have the semicircular canals, right? Which are your velocity detectors. So this is a duplex, right? If you're in if your townhouse isn't getting electric, your flat may not be getting electric. If the plumbing is bad in your flat, the plumbing might be bad in your townhouse. They share a blood supply. They share the same type of fluids, they share the exact time type hair cells, right? Diabetes, hypertension, um, metabolic syndrome, right? Um any kind of connective tissue disorders, neurologic conditions, Parkinson's, MS, I mean, uh migraine. It just goes on and on and on. So if you are a healthcare provider from HIS to a neurotologist, you're in the game.

SPEAKER_01 14:34

Right. And you and as you said, uh these conditions, balance and hearing conditions don't occur in a vacuum. They're comorbid with each other. If you have a hearing loss, can to continue that duplex uh metaphor a little longer. If you have a hearing loss, um it's it's you're an elevated risk by three times, even with a mild degree of hearing loss, of falls.

SPEAKER_00 14:57

And what we find, Dave, is that 30% of patients who come in for dizziness, vertigo, or imbalance, 30% undiagnosed, untreated, aidable, bilateral sensory and oral hearing loss. So what we recommend to our folks, you know, we we are we license or operate a hundred and fifty clinics in 39 states, audiologists, ENTs, neurologists, and we have some HIS owners. Sure. Like Madison Levine.

SPEAKER_01 15:42

Yep. She was on the podcast. Yeah.

SPEAKER_00 15:45

We have a number of of these folks who have pivoted what was originally a retail model hearing aid dispensary, and have pivoted to include a more medical model. Expand on that a little bit more.

SPEAKER_01 16:06

Uh, in terms of the emphasis and what opportunities that might provide for those who are fearful of disruptions. You talked about a number of disruptors, but you know, talk about that because I think that's a very important and insightful comment.

SPEAKER_00 16:21

You you have to be forward thinking about how do I position myself? How do I brand myself in this market so that people don't see me as just an alternative? How do I build a brand in my market that says, you know what, I'm a little special. I've got a little something extra. We're gonna give you, when you come to us, we have a plan of care. Maybe it's your cognitive function, right? Maybe you're gonna use, you know, uh a cognitive use screening. Maybe you're gonna do, even if you don't have a big balance lap, do a little steppin' Fakuda test, do a little GAN sensory organization test, do something. Well, or if they come in and say, I've got positional vertigo, treat them for BPPV, do something for them.

SPEAKER_01 17:21

Yeah, well, you know that this is a topic that's been near and near near and dear to my heart since my days at at Walter Reed or at Mayo or Miami, vestibular has always been an area that I think has been uh underutilized, underappreciated. And yet I saw very early on when BPPV became a part of the landscape. It was an area where audiologists, hearing care professionals can actually treat patients if they have BPPV. Exactly. And and by by you know expand on that a little bit more by putting them through the cantalith repositioning maneuvers.

SPEAKER_00 17:58

Yeah, so you know, we I just did this for the South African um private practice group. What we like to talk about is crawl, walk, run. I'm not telling you to be the next AIB, but could you have a$2,000 video goggle, which by the way is reimbursable? You have CPT codes. Could you do a little screening assessment? So if somebody comes in and they go, Oh, you know, I I almost didn't come in today. I I had a fall, but I'm feeling a little better. You can't just say, well, be careful.

SPEAKER_01 18:38

You can even use the steady protocol, the three questions. You know, have you fallen? Do you in the past year do you worry about falling or do others, I think the third one is, do others uh are they concerned about your falling? And if you if you say yes to one of those questions, you're at an elevated risk. And you know that this has been a topic that has been near and dear to Starkey's heart for the last five years when we introduced uh the first uh hearing aid that could enable a trusted contact to receive text messages in the uh hopefully unlikely event of a fall, so that none of us want to be that old woman from the 80s who fell on the floor and said, I've fallen and can't get up. And so even looking at just approaching it with those patients who are at risk for falls, maybe using the steady protocol questions and enabling that feature. I I can't tell you how many hearing care professionals who also happen to have a hearing loss said, ah, I, you know, falls are just for old people, and I don't turn that feature on, and then they suffered a fall while they were wearing the devices, and then all of a sudden they recognize this can happen to anyone.

SPEAKER_00 19:48

Absolutely. Um and it's it's it's it when I say preventable within reason. Yeah, as I said, gravity always works, gravity always wins. Yeah.

SPEAKER_01 19:59

Yeah. Well, that's why I think it is important um to have fall prevention week occur before fall, uh, because uh, you know, that's an area that we're continuing to work on in the sense of really a fall detection feature is fantastic. And we've heard that it provides peace of mind to family members to enable that feature. So, in the hopefully unlikely event that the loved one falls, they've received the alerts. But if they fall, they break their hip. It starts often, as you know better than I, that downward spiral. And um, and really I think the issue in the long run is to have the discussions for those professionals say, what do I do as part of this fall prevention week? Have the conversations with patients, bring in, think about the duplex rather than just the standalone hearing part of this. Think about hearing and balance, whether you just use an informal protocol. You mentioned some of the tests that can be done. If you say, well, that's more than I can accomplish, the$2,000 pair of goggles. Um, they can ask the three questions, they can talk about considering devices that have a fall detection feature, but then where do you see this going in the future? How do we how do we prevent falls before they occur?

SPEAKER_00 21:14

Well, one of the things is educating primary care doctors. Um, and also ENT. So for example, um, many of our friends in odolaryngology um have become the gatekeeper for patients with balance conditions. But uh now we happen to do, we have 32 locations with uh some of the largest ENT practices in the country. And we're now getting ENTs and audiologists to recognize that this is an extremely valuable, important part of your practice, right? So if the patient is if if if the patient doesn't feel validated, patient comes into you and you know I was dizzy, I, you know, I fell once, but my wife is worried about me. And if that patient doesn't get validated, why would they come back to you for their hearing, their nose, their throat, anything else?

SPEAKER_01 22:22

Well, I think you raise such an important issue, such an important point within many healthcare environments where there is audiologists, ENTs, many patients regard dizzy patients and patients with tinnitus with some apprehension because they know in many cases the diagnosis is very complex. It's often a diagnosis by exclusion rather than being able to go and do a blood test or some other definitive test, with the exception of BPPV, but but that point of validation when people are saying they're worried about this disruptor, whether it's OTC or big box or this or that or the other thing, I ask them not only what's their revenue per hour requirement, but you know, are they really afraid of engaging with the patient and understanding, hearing and balance their auditory and non-auditory symptoms and really validating them. I think you you the point about validation is so vital.

SPEAKER_00 23:21

The other thing is this idea that you can't make money in vestibular is fake news. Of course you can so if we do a full workup on a patient takes 90 minutes it's 100% reimbursable by Medicare.

SPEAKER_01 23:41

Which for for many people that will be something that can be another tool in their clinical tool belt to differentiate themselves in the community, to provide benefits to the patient, to consider the patient's overall health condition beyond just two ears that they're matching real ear measurement targets to to consider how it is that it will impact that patient's life.

SPEAKER_00 24:04

And I would tell our friends in that are HIS and audiologist you know if you look at the model of optometry ophthalmology and opticianry many of them are business partners I would urge everybody to stop the animus and find a way to make a business together. I don't think there you'll find many better situations than a doctor of audiology and a highly successful HIS business person how to build something really special together where you have almost just like you you go into the best ophthalmology clinics what do they have they have an optometry department they have an opticianry right look at this these are titanium frames from Belgium I pay nine hundred dollars for these frames that's without the prescription of a progressive prescription but it it took so it it took two people to make me happy right yeah it took the optometrist to get I've got a progressive bifocal even though I'm much too young for bifocal genetic I'm sure but it took a great optometrist to give me my progressive that made me happy and then it took a great optician to find the frames that I liked and the fitting and the comfort and everything that goes with it. So really if I have a message for your audience today find ways to make business together.

SPEAKER_01 26:01

Well that makes all the sense in the world you raise that being open and and you truly have done that by you you mention a number of professional organizations where the members are often at odds with each other. We even fight within the same discipline much less considering hearing instant specialists and ENTs how did I do this I'm friends with everybody. Yeah I'm friends with everybody and you're not I build bridges I don't burn them yeah and one one of my one of my mentors said to me only do what only you can do and delegate the rest that's an easy thing to say it's harder to do to have confidence like you said in terms of what your skill set is how others may complement that but to have the confidence to know what you add value in and also not to want to control everything when you can partner with others who may the optical example is a great one. You need in the same way that we need to ensure devices are providing the acoustic benefits and the cosmetic benefits and the physical benefits of fitting comfortably whether it's over the ear or in the ear devices the the analogy to glasses is the same. The best lenses and the corrections are great but if the frames don't fit you or they slide down your nose, they're not going to give you the optimum benefit and the other metaphor think about the best restaurant you've ever been to you at the back of the house you have the back of the house yeah if you can you can have Wolfgang puck in the kitchen yes if you don't have somebody managing that dining room or the bar you're gonna lose money you're gonna fail.

SPEAKER_00 27:43

Yeah well this idea that only I can do it right it it's just it's it's really I'm sorry but it's a sophomoric view. And you'll never see anyone that's accumulated real success in anything that is able to say that I did it all myself.

SPEAKER_01 28:05

You just can't so with that and we're we're just about out of time Go ahead because I have nothing else to say you have nothing else to say but what I want you to do is to give one or two or three tidbits for people listening who haven't really considered about balance in the manner of, you know, I always say balance is like you know it's often an afterthought when people are focused on hearing and adding balance you've you've provided us with the analogy of the duplex you've provided us with being open to different people with skill sets who are different than what we have in partnering unlikely partnerships.

SPEAKER_00 28:43

But give me one or two three things that uh are people listening today within the context of Fall Prevention Week what can they do to uh to to uh celebrate this if you will read read read so go to dizzy.com it's all free there's nobody's selling anything dizzy.com forward slash research you can download 50 60 of our articles papers then also on the website dr gan's blog dr gann's blog you can watch g-a-n-s for those who live under a rock and don't know how to spell your name you can you can um watch 50 or 60 video case studies of from infants to geriatrics everyone and just start to watch it and see if it interests you and then start to say well you know I I think I could do that no that's not so hard. I mean how long would it take three minutes or five minutes to screen somebody but just just think when somebody comes in with a hearing loss aren't you asking them about their vision you should because people do use visual cues if you don't want to call it lip reading or speech reading but it's clear that when people can see the speaker those visual cues help understanding so why not when the person comes into you look at them more holistically look at a human being and not just two earlobes.

SPEAKER_01 30:35

Completely agree and and you mentioned a number I mean there's comorbid conditions between hearing and balance I said a mild loss three times the risk it elevates uh even more as you have greater degrees of untreated hearing loss you talked about um cardiovascular disease earlier uh we know the recent uh results uh that were published from the Achieve findings show strong comorbidity I know a lot of a lot of professionals were disappointed with the overall lack of effect in the aging population but I think what I immediately gravitated to was that group of individuals aging individuals who also had elevated cardiovascular risk factors thinking about the patient as the whole in a holistic sense all had improvements dramatic improvements when they wore hearing aids versus the control group and it's really just emphasizing treating the entire patient hearing care is health care and uh you know it's not an isolation as a I would say let your client customer patient whatever you like to call them see you as a healer and not in a transactional relationship because transactional relationships are easy to disrupt. Right.

SPEAKER_00 31:53

And remember cost is only an issue in the absence of value.

SPEAKER_01 31:57

Exactly and you have to add value with every interaction you make and adding value is it cannot be commoditized. Caring can't be commoditized, we say and so caring about the entire patient. And so I think we'll leave it there. And I I thank you very much for participating in this session during Fall Prevention Week. Thank you for your dedication to working with patients in the field in the U.S. You mentioned over 150 I think you said locations but also you're international. You're you're Mr.

SPEAKER_00 32:30

Worldwide I mean we have AIB India workshops are available in English Spanish and Mandarin soon to be Brazilian Portuguese.

SPEAKER_01 32:40

Fantastic I thank you for your passion and your commitment to working with patients who have balance issues and to our listeners we thank you for listening to this episode enduring this episode of Starkey Soundbites with Richard and my sense of humor. If you enjoyed this conversation please rate us and review us on your preferred podcast platform. Share it with your colleagues your network share it with uh some of your competitors I mean uh we really want to see this focus on collaboration I think that Richard uh really discussed within this context central to uh fall prevention week and uh if you have other ideas as to topics that we consider in the show in the future please email us at soundbites at starky dot com. Thank you for listening and for viewing and we look forward to hearing and seeing you again in the future