Staging Hearing Loss feat. Dr. Keith Darrow

Can tinnitus and hearing loss be considered symptoms of the same neurological process/disorder? Dr. Keith Darrow, a neuroscientist and audiologist, joins us to challenge conventional wisdom about these conditions. As we explore his insights, you'll learn how the progressive breakdown of neural connections from the ear to the brain not only causes hearing difficulties and sensitivity to loud sounds but also leads to tinnitus and more.. Groundbreaking research from MIT addresses cochlear deafferentation, expanding our understanding of these complex issues 

Is it time to rethink how we classify hearing loss? Our conversation with Dr. Darrow uncovers the inadequacies of current classifications, which often use terms like "mild" and "slight" which downplay the seriousness. of hearing loss.  Dr. Darrow proposes using more precise metrics such as the  most-challenging four-frequency pure tone average and speech-in-noise ability and more, to provide a clearer picture of one's hearing health. By framing hearing loss as a progressive, chronic neurological condition, akin to diabetes or Parkinson's, we can develop better descriptions, management and treatment strategies.

Dr. Darrow advocates for a holistic, early and effective approach to detecting, diagnosing and treating hearing and listening difficulties. 

Join us as we explore the evolving nature of scientific inquiry, with Dr. Darrow highlighting the importance of continual refinement and openness to new perspectives, ensuring better outcomes for those affected by hearing loss and tinnitus.

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Transcript

Dr. Keith Darrow: 0:00

The system we have is broken.

Dr. Douglas L. Beck: 0:03

Yeah, it's not a great system and you could argue well, it's the one that we've had since World War II and absolutely you can make that argument. But I think we're not maximizing our ability to communicate with patients when we're using terms like slight and mild.

Blaise M. Delfino, M.S. - HIS: 0:22

You're tuned in to the Hearing Matters podcast, the show that discusses hearing technology best practices and a global epidemic hearing loss. Before we kick this episode off, a special thank you to our partners Redux faster, drier, smarter, verified Cycle built for the entire hearing care practice. Otoset, the modern ear cleaning device. Faderplugs, the world's first custom adjustable earplug.

Dr. Douglas L. Beck: 0:55

Good afternoon. This is Dr Douglas Beck, and today we are interviewing Dr Keith Darrow, my dear friend, dr Darrow is a neuroscientist, has a PhD in neuroscience. He's also an audiologist. He's a podcast host. He's the founder, spokesman and content producer and CEU educator for the Excellence in Audiology program. So what we're going to do today we're going to discuss staging hearing loss. One of the things that you and I've been talking about quite a bit in 2024 is the fact that hearing loss and tinnitus may be kind of sort of almost the same sort of thing.

Dr. Keith Darrow: 1:35

Can you talk a little bit about that before we get into today's topic? Tinnitus and hearing loss not as two different medical conditions, rather they're symptoms of the same neurologic condition, and what I mean by that is, as we get older, we acquire hearing loss. It is by far the number one cause of global hearing loss 1.5 billion people worldwide. Probably 2.5 billion people in the next 20 years At least those are the estimates. And really what we're dealing with as we age is not just an inconvenience, it's not just oh, I don't hear as well as I used to, oh, I have some ringing in my ears.

Dr. Keith Darrow: 2:20

What you're dealing with is a progressive degenerative disorder. You're dealing with a breakdown of the neural connections from ear to brain and when that happens, you will start to experience a lack of clarity, one of the big symptoms that comes with it. You will start to experience difficulty hearing and background noise. You will start to have sensitivity to loud sounds. Hearing and background noise. You will start to have sensitivity to loud sounds. You may start to become more forgetful and have memory issues and you will have tinnitus.

Dr. Keith Darrow: 2:51

So I've sort of been trying to break it down and make it really simple and teach people and say tinnitus is hearing loss, hearing loss is tinnitus, so that we can start to realize that they're one in the same. Now let me just get this out there before somebody you know decides to pull their AirPods out of their ears and stop listening because they think I'm nuts. Obviously, there is a small contingent, a very small contingent, less than 5%, where tinnitus does not have any relationship to the auditory system. I'm not ignoring them. I'm just here to talk about the vast majority and how it's related to hearing and audition.

Dr. Douglas L. Beck: 3:33

And a lot of this comes from that new paper. I want to say it's about four months ago out of MIT and that was from your mentor, Dr Lieberman, right?

Dr. Keith Darrow: 3:43

Right. So Dr Lieberman, dr Stéphane Maison the two people I sat with every day, had lunch with, put out six papers in just a few years, during my PhD, during my thesis work. The paper that came out I'm going to basically summarize that said two things.

Dr. Keith Darrow: 4:05

Basically, tinnitus is inextricable from hearing loss. Otherwise said, tinnitus is inextricable from cochlear deafferentation, which is really the fancy way of saying as the nerves break down from ear to brain. I want to make sure we're clear here. This was a human based lab from the temporal bone lab. So this was. You know. They looked at people, they looked at their ears and their brain afterwards and they tied the tinnitus to the loss of neural connections from ear to brain. That's number one. Number two the reason people have tinnitus with quote unquote normal audiometric hearing is due to cochlear deafferentation. It is not due to something else. So we can't tell those people who come in and say I have this ringing in my ear. You do a basic audiogram and say well, your audiogram looks normal. No, Basically saying, the audiogram cannot tell you that a patient does or doesn't have tinnitus. The audiogram does not confirm or deny that there's a loss of neural connection. So that to me, was huge, because I think it is you see it all the time.

Dr. Keith Darrow: 5:14

I see it all the time. Providers say my patient has tinnitus. But quote, unquote, normal audiogram.

Dr. Douglas L. Beck: 5:21

And I think this gets us to a very interesting question, which is the definition of auditory neuropathy. I think many gets us to a very interesting question, which is the definition of auditory neuropathy. I think many of us look for auditory neuropathy with auditory dyssynchrony, but auditory neuropathy, in perhaps its simplest form, is just this deafferation that you're talking about, right.

Dr. Keith Darrow: 5:37

Exactly exactly. We all think of it as something bigger. We all think of Chuck Berlin sitting down at his piano playing songs of auditory neuropathy and dyssynchrony. That is its own thing, absolutely found in children, 100%. But we have to realize auditory neuropathy is the neural connections from ear to brain breaking down and they can be in different situations, of which presbycusis. What we do lose is the connections of the inner hair cell, of the sensory receptor, from that sensory receptor to the brain. That's what we lose as we get older.

Dr. Keith Darrow: 6:15

That's different from the traditional auditory neuropathy, which is why presbycusis, auditory neuropathy, tinnitus right, I used this term before. I think you're used to it by now, but most people in this field don't realize what we're talking about is a chronic condition that specifically targets the nervous system. That's why we refer to it in our clinics and all of my books and all of my scientific writings and not just me, but most people in the medical field will classify it as a progressive degenerative disorder. A paper from Harvard Health talks about how hearing loss is the number one chronic neurologic condition on the planet.

Dr. Douglas L. Beck: 6:58

Which is a very, very good framing for this discussion today, because what I want to talk to you about is how do we actually speak about hearing loss? And just to put it a little bit in focus, you know, when we go back to World War Two and we talk about normal hearing is perhaps minus 10 to plus 25 dB on an HL scale. Then we could say mild loss might be 26 to 40, moderate 41 to 70, severe 71 to 90, profound 91 and above, and we might have moderately severe mixed in there and slight mixed in there and things like that. I've always found that to be a rather inadequate system. I want to get your thoughts on that.

Dr. Keith Darrow: 7:37

Well it's. I mean, you taught me this phrase right. These are categories of convenience, these are human adjectives that are used to describe a medical condition. That doesn't make any sense. The same way, it doesn't make any sense when it comes to word recognition score and the classifications of good or excellent or very poor for either category. They just don't. They don't convey the actual problem. They don't convey, dare I say, the seriousness of the medical condition. They almost underserve the patient. I mean, how many people see slight or mild? And by the time they drive home they've already convinced themselves. And by the time they drive home they've already convinced themselves ah, it's not a big deal Point well taken.

Dr. Douglas L. Beck: 8:27

Here's the thing we have about 335 million people in the USA. We have the Global Burden of Disease Study that Ear and Hearing published just in the last few months, showing that about one in five people in the USA has hearing loss. Now, of those, about 70% are what we would classically call, you know, mild, and I think this is the problem is that most of those people will never seek help because somebody told them they have a mild loss, and that's the clear majority of people who have hearing loss. And so I'd like to explore with you how we might go about using some better descriptors. What type of words and system would you recommend so that the 70% of people who have demonstrable hearing loss and are asking for repeats and are having difficulty with speech and noise, they don't walk out saying, oh, it's nothing.

Dr. Keith Darrow: 9:19

Two things. The first one I have to comment on is I know there's a history to it and I don't want to make this a history lesson, but slight is a category of hearing loss, always has been, always will be and always should be, because normal hearing, as originally studied, went up to about 13 dB, which is why 15 was considered a category, from 15 to say 25 of slight. So that is a real category. We can't just throw that out. My point being the study you're referring to. That says 73 million Americans have hearing loss, documented hearing loss. It doesn't include the slight, doesn't include subclinical, and then it doesn't include everything you talk about every time you're on stage, which is the people with supra threshold listening disorders who are just can't get by in background noise, have tinnitus et cetera Exactly.

Dr. Douglas L. Beck: 10:14

And so what happens, you know when you go back into the archives and you look at those original studies, normal hearing was, on average, 15 dB HL. And so when you're thinking about that, and yet the categories of convenience say zero to 25 is normal, we're already eliminating people who could have potentially 25 or 30 dB of hearing loss. I mean, you know, supposing that you're an infant and your thresholds are minus fives, minus tens, and then you go for your first hearing test perhaps entry into the military or grade school or something, and your hearing is 20. Well, if it was minus five, and now that your thresholds are 20, that's a 25 dB loss that nobody's ever going to talk about.

Dr. Keith Darrow: 10:55

I've heard you say that before. I love it every time you say it because it just drives home the point. Of imagine if you had that preliminary and it was minus five Because this is the issue.

Dr. Douglas L. Beck: 11:10

you know, when I talk to another audiologist and I say the patient has a 38 dB, four frequency, pure tone average, he or she has some idea. But then I also have to say well, it's a flat loss, or it's, you know, a high frequency loss, or I have to qualify it Mild to moderate through 2000,.

Dr. Keith Darrow: 11:25

Sloping down to like I get it and I teach this to my undergrads in school. But it's just when you think about the human to human conversation, how funny that kind of is that we rattle off all these terms and the patient's like so it's normal. For my age.

Dr. Douglas L. Beck: 11:41

No, this is very, but this is exactly the essence of the problem. You know, I generally will use a four frequency average and I'll talk about their speech and noise ability. So that four frequency average. The reason I do that is that tells us how loud sound has to be for them and how clearly do they hear, because that's really what they want to know. I mean, let's face it, 90% of all patients who come to see any of us in hearing healthcare primary complaint is they can't understand speech and noise. And let's not get into the fact that about 80 or 85% of hearing care professionals don't measure it. But if they did, that's the number that the patient cares about. That's the one that they want us to quantify and qualify. That's the one they want us to fix.

Dr. Keith Darrow: 12:23

Well, yes, yeah, you're right, this isn't a podcast about speech and noise. But I agree with you a thousand percent that. How dare you right? I'll be the bad guy here, I'll say it, Doug, you said it nicely. But how dare you? If your patient says I can't hear in background noise, how dare you ignore that? And essentially, 85% of hearing healthcare providers are ignoring it by not quantifying the patient's speech and noise, by not quantifying their pain. But back to your point about okay, so these categories of convenience, these silly words. So what's the alternative, what's the option? And ultimately.

Dr. Keith Darrow: 13:02

I want to go. I'm going to say it again for the third time because it's really important. Hearing loss and tinnitus are part of a progressive degenerative disorder, auditory neuropathy, like you talked about. I love it. It is a chronic neurologic condition, and so for me, this was about four years ago when I had one of those light bulb moments it wasn't that bright, but I had a light bulb moment of.

Dr. Keith Darrow: 13:29

Neurologic conditions are historically staged, whether it be type 2 diabetes, whether it be dementia, cancers, parkinson's schizophrenia neurologic disorders are staged. And so I just had that moment of well, wait a second, why isn't hearing loss staged? And so I did some research. Right, like, what is disease staging? Right? Basically, it's this classification system that's used to take diagnostic findings and basically produce a cluster of patients based on etiology, pathophysiology and severity. I do think that's important, but I don't think the mild to profound is the right way to talk about severity. And so, again, this is like Merriam-Webster dictionary stuff right To a stage is to determine the phase or severity of a disease based on a classification of symptomatic criteria.

Dr. Keith Darrow: 14:32

I think symptoms belong in there also, especially given everything we know about again, quote unquote hidden hearing loss or our inability to do a good job at measuring our patient's complaint, and so for me this just made a ton of sense, and it's now been. Look, we're on year three. I love that this is becoming a revolutionary idea. I love that there's been recent mentions in other audiology journals about a staging system. But for three years now in our clinic we got rid of the silly words and we have been staging hearing loss stage zero through stage four, because that's what aligns with the other progressive degenerative disorders that all medical physicians understand.

Dr. Douglas L. Beck: 15:19

And you've got the staging outline in your book, and I know you've written five or six books, I think it was in the first one that I read.

Dr. Keith Darrow: 15:30

Preventing Decline was when we first sort of rolled that out to our patients, because that came out in 2020. And that is when we started in our clinic. So yeah, we're on year four now, now that I realize it yeah, and so that are four of doing this.

Dr. Douglas L. Beck: 15:43

So people who are interested in seeing the staging and the exact words of that can find it in that book. But in the meantime, can you outline that for me Well?

Dr. Keith Darrow: 17:07

yeah again. So, the point being right, I spent so much time in, perhaps, covid it was a little bit easier to have some extra time on my hands. But you know, I looked at Alzheimer's disease, which has seven stages, parkinson's, which has five stages. We know about cancer, we know about diabetes, and it's four stages. And so I really had to sit and formulate what are stages of hearing loss, what would be the diagnostic criteria, what would be the symptomatic criteria and no matter what and I still can't, because I looked it up recently, because we did a webinar on staging hearing loss I still can't find anything on the internet about stages and hearing loss, and what I mean by that is go to the American Diabetes Association, go to a dementia website, go to Parkinson's.

Dr. Keith Darrow: 18:02

You can, as a patient or a provider, you can learn about it. The point being see what staging also does, is it conveys to the patient it will continue to get worse, yes, and without treatment it will get worse faster, right? Ultimately, I think that's the big problem, what that paper told us, the one you were referring to with the 73 million Americans that just came out. While that number is troubling, what's disturbing is that we're treating less than 10%. So the system we have is broken.

Dr. Douglas L. Beck: 18:38

Yeah, it's not a great system and you could argue well. It's the one that we've had since World War II and absolutely you can make that argument. But I think we're not maximizing our ability to communicate with patients when we're using terms like slight and mild. If I just had a slight or mild headache, I wouldn't worry too much about it. But if I hear it's a migraine, then I'm going to take some steps to try to avoid those triggers and maybe to better medically manage it. And of course that's true with cancer and with Alzheimer's and with a million other things. So I like the idea of staging and I think you've already said that you incorporate more than just pure tone thresholds into this.

Dr. Keith Darrow: 19:18

I'll do the quickest review possible. Stage zero right. No evidence of damage to the auditory system. Like that is our. The person who comes in who needed a test for work right. Like that is for the person where everything is fine. Not a single test you did, whether it be OAEs, extended high frequency patient has no symptoms, like nothing's wrong.

Dr. Douglas L. Beck: 19:40

Right, it's just verification that there's nothing wrong.

Dr. Keith Darrow: 19:43

Exactly Perfect, perfect, perfect, which you know in cancer, you know you, probably you know this that stage zero could mean an early sign.

Dr. Keith Darrow: 19:52

But for the way we're defining it and yes, it's in preventing decline, stage one, we're talking about early stage hearing loss. You have a 15 to 40 DB hearing loss on the audiogram and I'll come back to which frequencies diminished OAEs and extended high frequency loss and and our, our sort of final statement is with limited impact on cognitive function. Now this is where some people like well, what do you? Well, what does that statement mean? Well, we do cognitive screenings and we do quicksand and so we're able to make a comment reliably. And, by the way, we have a whole chart that goes with this right Like this isn't just from one single piece of paper, it is for the patients, but our providers, just like an oncologist has to learn the chart of what is included, what is not included in the different stages of hearing loss. So when I say on my report to my patient, with limited impact on cognitive function, that has meaning to the providers and to the patients because we'll review how, on quicksand, they did well on the cognitive screening they passed.

Dr. Douglas L. Beck: 21:04

So hopefully that makes sense. This is an important point because it's important to know. Aaa says that's within your scope of practice, as does ASHA, so we don't need to discuss that in any more depth. But you can find that in the scope of practice statements, right?

Dr. Keith Darrow: 21:19

And for me, look, scope of practice is what you should do.

Blaise M. Delfino, M.S. - HIS: 21:25

Yeah, I believe.

Dr. Keith Darrow: 21:25

That's why they put out that statement, even though they're not as harsh as maybe I am when I say if it's in the scope of practice, you should do it. And people ask me all the time about criteria. If your patient has hearing loss, your patient has difficulty hearing in background noise. If your patient has tinnitus Look, these are simple. These are red flags that your patient may be at increased risk. So that is our rationale for doing cognitive screening so often in our patients. Now let me address this before I go into stage two, stage three, stage four, because the most common question I get is what do you mean by 15 to 40 dB?

Dr. Douglas L. Beck: 22:02

loss Okay. So that's a great question, and we're talking DBHL Of course. And you're talking about a three-frequency pure tone average, right?

Dr. Keith Darrow: 22:11

Yes, but we take the worst three.

Dr. Douglas L. Beck: 22:14

Okay, so it could just be a high frequency loss in this case.

Dr. Keith Darrow: 22:18

But see, even when you say that as if that's not meaning and I know that's not how you meant it but you hear this all the time. But it was normal sloping two as if we're minimizing the fact that there is significant damage in a part of the cochlea.

Dr. Douglas L. Beck: 22:35

Well, a three-frequency pure tone average generally is 5.1 and 2, 500, 1,000, and 2,000 hertz. I always say you should do all frequencies. So now you've got 10 frequencies rather than six, right? So if you've got 10 frequencies and if you're doing 8k, 6k and 4k, if they had a 65 dB average let's say that 4, 6, and 8 were all at 65,. You'd call it a 65 dB loss. That's what you're using in your staging, exactly.

Dr. Keith Darrow: 23:05

Exactly To just use 5, 1, and 2,. It's a bizarre concept To use 5, 1, 2, and 4 as the 4-pure tone average. It's's a bizarre. Now, I understand historically, the intention being where can the person hear speech right? Pure tone average is what we use to compare with SRT. Where can the person hear speech at its lowest level? I understand the historical significance of that, but when it comes to diagnosing, we are going to look at four, six and eight, because that's a real big indication of what's happening a little bit more up in the apical areas, what's happening a little bit more down and truly. That's why the person's there. And, by the way, you're also going to catch the people who are, dare I say, normal through two, normal through four, right, because if you use the traditional pure tone average.

Dr. Keith Darrow: 24:02

But if you just use that pure tone average from five, one and two, which, by the way, only represents oh I don't know about 25 to 28% of the overall cochlea, that doesn't really make sense.

Dr. Douglas L. Beck: 24:15

Yeah, and I think this reframing of the three frequency pure tone average makes good sense because we're not trying to say where is your hearing normal? The question is, is your hearing normal where it matters most for speech perception? The three frequency four frequency pure tone average in the SRT, one was considered a check. On the other, you're exactly right, that was more about loudness and verifying and validating that your SRT and your PTA were within five or 10 dB, whatever that number was. But they weren't about clarity and I think if you're looking at the three frequencies with the worst pure tones now we're starting to approach something that's a little bit more in alignment with the patient's chief complaint. You know the reason they came in to see you.

Dr. Keith Darrow: 25:01

Exactly exactly, and so that's been my issue with the. You know, the hearing number that has been out there is that we're not really getting at and we're almost saying 4, 6, 8, 10, 12, 16, 18, we're saying those frequency ranges don't matter, which is wild. We've known for 30 years that extended high frequency hearing contributes to our ability to hear in background noise, which is why patients come to see us. And you said it earlier, what was it? 70 to 80% of patients are in that mild range.

Dr. Keith Darrow: 25:37

Absolutely yeah 70 to 80% of patients are in that stage one to stage two phase. Now, all of a sudden your brain's like, well, that can't be good, it's not good. Right, I believe it a thousand percent, and I think everybody on here knows this Dr Charlie Liberman at Mass Eye and Ear who coined the term hidden hearing loss. Dear friend, mentor, my son's name is Charlie, that's how much Dr Charlie Liberman meant to me. But hidden hearing loss is a strange word.

Dr. Keith Darrow: 26:08

Invisible makes more sense and I actually think finally our field is starting to understand that subclinical is really the best way to diagnose and think about that type of hearing loss. Because again, here's another hallmark feature of a neurologic disorder is that there's a pre-symptomatic phase, meaning that it's developing before the patient knows it. And we know that the breakdown of neural connections actually begins in the third to fourth decade of life for humans, which you know, most people wouldn't say that they have any hearing loss or any problems at that age. So three frequency, pure tone, average of the worst three. Okay, I haven't, I haven't come up with a coin.

Dr. Douglas L. Beck: 26:50

We need an acronym. This is audiology. We need an acronym. I know, I know, I know.

Dr. Keith Darrow: 26:55

So, like stage one, is that early stage, stage two being the mid stage, wherein thresholds are now between 41 and 70. And, by the way, you'll notice these categories of numbers I'm using 15 to 40, 41 to 70. Again, they go back to. I hate buzzwords, but there's a buzzword out there of holistic. This is holistic. This includes the three worst frequencies otoacoustic emissions, extended high frequency loss, cognitive screening, quicksand. This is holistic.

Dr. Douglas L. Beck: 27:29

This is a very different system than what people are used to and I think if you just look in the book itself and you see the chart, you know it's a little bit hard to get your arms around it because of some of these idiosyncratic features that we're talking about now. But I think that that does explain it much better and gives you a feel for oh, that's why that's there and that's how we use it. Dr Darrow, would you mind could we attach a copy of the staging to the podcast so when people go to hear oh, definitely, yeah, yeah, I can get you something pretty Yep.

Dr. Keith Darrow: 28:03

Absolutely, if you would do that I think the last thing I want to say is what staging has also allowed us to do is to sort of have that holistic conversation and you've seen my form before that holistic conversation of okay, this is your stage of hearing loss, Given what we now know and given all the correlational data out there, it's time for us to have a conversation about how this increases your risks for other conditions, including cognitive decline, including the risk of a traumatic fall. Like this is a different, holistic, medical way to discuss with your patients their hearing loss, the potential impact of untreated hearing loss and, dare I say, the benefits of treating hearing loss, which then helps us easily lead into our post-treatment options of cognitive rehabilitation and everything else we do with our patients.

Dr. Douglas L. Beck: 28:59

Yeah, and this is an important point that hearing loss is a progressive degenerative disorder and it's not just going to impact the auditory sides of the cochlea. The labyrinth is also degrading at, you know, in a parallel universe as one ages and has more and more exposure to ototoxic drugs, head trauma, noise exposure, all of these things. And I think that if we're just going to try to focus on hearing and the pure tone average, we're going to miss the forest for the trees. I think we are so overdue to take what we know and start applying it to patients. But let me ask you this, because this comes up all the time Well, if you talk to patients about hearing loss and you talk to them about tinnitus and fall risk and cognitive problems later, isn't that a scare tactic? Aren't you just trying to sell them hearing aids?

Dr. Keith Darrow: 29:53

Well, that was a two-part question. The first one is yes, it is scary. It's not used as a scare tactic. No, under no condition should anybody ever use the consequences of untreated hearing loss as a scare tactic. And if you get caught doing that, you should be locked up in a hearing health care jail. I don't know where that is, it might be in Doug's basement, but wherever it is, that's where you should go have your license taken away, because that is unethical. I also believe it's unethical to not educate your patients about their medical condition and about what the future may hold for them.

Dr. Keith Darrow: 30:32

Right, this happens to every one of us every time we go see a doctor about something being wrong. Right, this happens to every one of us every time we go see a doctor about something being wrong. Right, the doctor looks at you and tells you, point blank this is your condition. There are treatment options available. If you begin treatment, you will begin to experience or notice X, y and Z. If you do not move forward with treatment, my fear is you will experience A, b, c. With treatment. My fear is you will experience ABC. That's how the medical field levels with their patients, whether it be type two diabetes, I mean. If we convey to an adult that type two diabetes wasn't that big a deal and you know, I mean I don't see a lot of hearing loss, I don't see a lot of diabetes. Maybe come back in a year.

Dr. Douglas L. Beck: 31:14

Yeah, I think this is key and I think this is what most of us have been trained to not do. I mean, we are sort of kind of the people who say that's no big deal, a little high frequency loss. I see that we're taught that. Yeah, and it's really unfortunate. It's time to change that. When we see demonstrable hearing loss or we have signs and symptoms of supra-threshold listening disorders, subclinical hearing loss, the inability to understand speech and noise, when people are complaining about auditory difficulty, even though they may or may not have normal, pure tones, it just needs further investigation. We're the audiologists, right. If we don't discover and if we don't work at the top of our license to do everything we're supposed to do, nobody else is going to do it.

Dr. Keith Darrow: 32:01

Exactly, and I feel like this gets me back to because a lot of it is rooted in my why, and one of the big ones is okay, nationwide we're treating less than 10% and if you ask any hearing healthcare provider why, there's always the default of well, because of the costs, when you and I know that there are countries out there developed countries, first world countries that are giving away hearing healthcare for free. They're giving away hearing aids for free as part of their socialized medicine program.

Dr. Keith Darrow: 32:37

But I think ultimately it boils down to health literacy and not understanding what it means to have hearing loss or tinnitus, what it means to live without treatment for hearing loss and tinnitus. I mean I often half wholeheartedly joke that about 93% of people diagnosed with cancer readily say yes to chemotherapy. They readily say yes to poisoning their body, taking their body to the brink of death, so that they can then have a cancer-free or less cancer, so that they can live a better, longer life. We need to develop a value proposition that is much stronger, so that our patients understand what it means to treat, what it means to not treat, and then let them make the decision. That's when a patient has the right to make their own decision, and I think if we change the conversation, we're going to see the opposite. We're going to see 90% of people say yes and maybe 10% say no.

Dr. Douglas L. Beck: 33:43

I think that health literacy is a huge issue. You can't make decisions when you're not conversant in all the factors right. So this is our responsibility as hearing care professionals to make sure that the patient knows the total impact. Dr Darrow, it's a joy to see you. I am so delighted to spend some time with you and I want to thank you and I hope that for the hearing care professionals watching and listening and thinking this through, this may not be a perfect staging protocol. There might be a much better one, although I think this one's pretty darn good.

Dr. Keith Darrow: 34:14

But this is our first go at it, you know, and maybe we can modify and change and come up with something that all of us would say we ought to bring this to ASHA or AAA or IHS, I take that completely in stride, because even the way we're doing it I said it's been three or four years, sure, I didn't put it in a lock box and say never again will I touch it, right, the form has been evolving, the way we think about it, what we include. That's the way science works. And so, yeah, I don't think that there's going to be, and by no means do I believe my system is perfect whatsoever. I've had so many conversations with you and gone back with my red pen and thought, okay, well, now that I thought about it, now that I read this article, so you're right. As a field, I think step one is we need to do something different.

Dr. Douglas L. Beck: 35:02

All right, Dr Darrow, I want to thank you so much for your time and your expertise. It is a joy to see you, a joy to work with you, and I will look forward to the next time. Take care, Dr Beck. Thank you.