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Full Interview: AudA Audiologist Keith Chittleborough on World Hearing Day

Mar 1, 2024

This World Hearing Day (WHD) 2024, we invited self-described ear-obsessed Victorian audiologist Keith Chittleborough, owner of Earman Audiology, to share his thoughtful, yet entertaining perspective on the state of audiology in Australia. 

Keith provides contractual audiology for both Victorian Hearing, one of Victoria’s largest independent audiology practices, as well as an ENT clinic. Holding a Bachelor of Behavioural Neuroscience and a Master of Clinical Audiology, Keith enjoys providing client-focused and evidence-based hearing aid prescription, focusing on the importance of neurology over technology.

Keith Chittleborough

Here is our full interview:

What does this year’s WHD theme ‘Changing Mindsets: Let’s make ear and hearing care a reality for all mean to you?

World Hearing Day hopes to improve global hearing healthcare, by raising awareness of the sociological factors effecting the adoption and implementation of audiological services—and to do so through activities, such as this Q and A which, dear reader, is before your eyes.

And, yes, I’m all for this kind of campaign. But goals like those above seem a little, well, grandiose for a simple audiologist like me.

Now, sure, I change mindsets all the time. I’m (mostly) a rehab audiologist. My daily love is the diagnosis of hearing loss and the fitting of hearing aids—in suburban Melbourne, and for a range of independent providers. Not a day goes by when I am not changing a patient’s mindset. It’s inevitable. Medical literacy around hearing loss is about as low as it gets. Our patients are going to have many, shall we say, dubious preconceptions coming in. And that’s ok. It’s great. I can’t wait to find out about them. That’s why they’ve need people like us to help them.

But I do this sort ‘mindset changing’ one to one. In person.

The idea of writing the right thing, right here, right now, that would make a difference on a national, let alone a global scale is, just, well—inconceivable.

So no, to me, World Hearing Day 2024 means that I have an opportunity to reflect. To ask myself, not what should others do, but how can I do better? To take personal responsibility—not for my industry—but for myself. And maybe, through these shared and fumbling reflections, I can provide a little space and inspiration for my fellow colleagues to do the same thing.

According to the WHO 80% of ear and hearing care needs remain unmet globally. In Australia this is particularly true for Aboriginal and Torres Strait Islanders and those living in regional and remote communities. What do you see as some of the barriers to access to hearing care?

I don’t work with Aboriginal and Torres Strait Islanders, or remote communities, so I can’t comment on those specific needs, but I can point out that even in my backyard, in suburban Melbourne, our typical patient with age-related hearing loss (presbycusis) is extremely ‘remote’ from the hearing aid shop on the street corner a block from their house if they never actually enter the clinic’s doors.

Why’s that? Well, let’s talk about my mum.

My mum’s in her 70s—going on her 90s. She has legs about as stable as the waving arms of those wacky-inflatable-flailing-arm-tube-men you see outside used car lots. And yet, does she use a walker—let alone even a walking stick? No. And how many times has she fallen? There have been footy-sized haematomas, bone fractures—and lost teeth. Another bad fall and it could kill her—and yet… She chooses not to use an aid.

Why? Why do those suffering from presbycusis take so long to enter our clinic doors?

I think one reason is fear.

Fear of being judged by others, but also the fear of the truth. Finding that hearing declines, that we age and—ultimately—that we are mortal. I doubt most of you have heard of this word: thanatophobia. It is the fear of death.

Is this the whole story? Of course not. People are complex, and fascinating. I keep tyring to understand them better.

What are the real costs and consequences of not meeting these needs?

“I wish I’d done this earlier.”

I get that a lot. Perhaps I’ve just fitted a hearing aid for the first time to a reluctant user, waiting 5-7 years to come in those clinic doors, or perhaps I’m fitting a second pair to someone whose previous aids spent 10 years improving the speech-perception of their bedside drawer.

It’s a nice thing to have said to you. It feels good. It’s a real Instagram moment. But, let’s be honest, they represent a fraction of the reality.

Too many people leave it too late. Hearing loss worsens—the cochlear declines—the brain slows—the body fails. The cost of not meeting needs early and correctly is that we may never meet those needs, because we’ve lost the critical window of opportunity, or broken the faith of our patient.

It don’t think I need to explain the consequences of untreated presbycusis or early onset hearing loss (social isolation, unhappiness, cognitive decline…) I do think I need to make myself stop and think: did I do everything I could in that appointment?

And do we as a profession—as individuals, as businesses, and governmental funding bodies—do anything to feed the fear of our patients, already so scared and reluctant to seek our help?

What do you think are the biggest misconceptions and stigmas affecting Australia’s mindset about hearing as health priority for action?

I think Australia has done a commendable job, and of course it’s not surprising that hearing loss doesn’t attract the same attention of, say, diseases that you may, unfortunately, die quite rapidly from. I think it’s important to put things into perspective. Personally, I don’t want the same kind of attention given to age-related hearing loss as, say lung cancer, with which my Dad recently had the pleasure of, culminating in a radical lobectomy (non-smoker, BTW). But what I do really want is that whatever resource we do have, especially those supplied through taxation, be used well.

I think a typical misconception is that if we supply money and resources towards a problem, we solve it.

I’m not sure that’s the case. Now, remember, I’m just a small thinker, and I think of small things. And I think about this little thing called data-logging in hearing aids that tell us if a patient does and or doesn’t use a hearing aid, and it’s kind of hard to argue with. And often I wonder if I truly deserve funding when I supply a hearing aid through the government’s Office of Hearing Services program and my patient’s daily data-logging is under 8 hours…

Or 4 hours…

Or 1 hour…

Or 0 hours.

Hearing health intersects with many other areas of health but is still not well understood by other health providers and professionals. What do you think is impacting this understanding and how can we begin to change the health conversation around hearing and hearing loss?

Keep the message simple: Hi, GPs! Ear complaint? Just refer to an audiologist.

Around 10 years ago, one Saturday morning, I woke up with a blocked left ear. A full muffled sensation. A bit of mild tinnitus. I have consistent earwax accumulation that requires micro-suction. So, obviously, I sat on my sensations, until I went into the clinic. No wax. Normal tympanometry indicating normal middle ear function. Self test: ooh, by golly, I had a 30 dB low frequency sudden sensorineural hearing loss.

My cochlear was in trauma. Parts of it potentially dying.

Even then, I waited, until a much smarter colleague than me told me to go to the Royal Victorian Eye and Ear Hospital for consultation, but mainly for a course of prednisolone (oral corticosteroids)—the theory being, keeping it simple, if sudden sensorineural hearing loss is inflammatory in nature, these drugs reduce inflammation with minimal side-effects.

I recovered.

Nowadays, I don’t go 6 months without treating a patient whose sudden sensorineural hearing loss was sat on by a GP, who gave drops for ear wax or a nasal spray, and who didn’t see an audiologist for weeks or months later, and the theorized critical window for treatment via oral corticosteroids, or trans-tympanic membrane injection, was lost.

And it’s hard not to get very bloody angry… and then I think, I should have known better too, when it happened to me. I waited. Even with all my knowledge and time and incredible vested interest in my own health, I was so close to missing my window of recovery. It is so easy to make mistakes. There are some very understandable reasons for those mistakes. But they are still mistakes.

Please, GPs, just refer. Otoscopy is not a diagnostic tool.

(If the above is the carrot, here is the stick: do you know that some medical negligence lawyers would be very interested in taking on a case of sudden sensorineural hearing loss that was not referred by a GP in a timely manner? Just saying.)

What information or engagement is needed to change public perception and understanding of hearing health and hearing loss?

If I could wave my magical sociological-changing wand, I’d make it widespread knowledge that audiologists are the experts in the detection of hearing problems and initial treatment triage of ear-related disordersand that we thoroughly deserve this accolade.

Now, lacking any magical wand, there are three main problems in need of improvement:

  1. A huge proportion of the population does not even know what an “audiologist” is.

Solution? I think Audiology Australia has recently done a great job with this simple message. But I also think we miss potential educational opportunities. I have a one-year-old son. His new-born screening was conducted by a nurse who didn’t know how the machine worked. For many (and definitely the baby at least) this was the first time ears were discussed medically. Could we do something different here, given the need for new grads to gain experience?

  1. A large number of audiologists do not provide a higher level of desired services, such as cerumen removal with micro-suction via a medical microscope (or head-based magnification), or even something as simple as packing a mastoid cavity.

Solution? Why don’t they? Lack of motivation? Maybe… Lack of incentives within their organisations? Probably a large part. (For example, I never wanted to do VRA on children ever again after leaving Uni. And I probably never would have re-learnt if I hadn’t been asked to help out at an ENT about two years ago. Now, it’s just another value add included in my salary rate).

  1. For many of our potential patients, the audiologist or hearing clinic is equated directly to hearing aid sales. Especially on this latter point, I wonder if the message of ‘free’ hearing screenings/ tests and the focus on the hearing aid ‘product’ coming from the larger points of contact between our industry and our potential clients send the message that we are, in fact, a diagnostic and rehabilitation-focused profession?

Solution? This is a tough one. I get it. Our pay checks are in the hearing aids. And our customers want the ‘fix.’ But are we going about it in a way that’s going to be long-term sustainable revenue stream, or are we just maximising profits on the way to the bottom? The alternative? Offer the community new businesses with perhaps a different message, and see what flies.

What are the biggest or most frequent misconceptions you have encountered?

Probably the biggest misconception from prospective adopters of hearing aids is that the technology inside the devices will fix the problems of their hearing loss. Great outcomes can be achieved at all price points, with all brands and styles. Instead, it’s who you see—the provider—that has a far greater impact than the actual hearing aid supplied.

My favourite hearing aid is Lyric: the 100% extended-wear device that sits 4mm from the eardrum and stays in the ear for months at a time (it’s analogue by the way, and can outperform devices with directional microphones and ‘AI’ processing). It’s an amazing device, for the right person, but the downside is that it is clinically hard to fit, and doesn’t work for a large percentage of candidates.

I track statistics (as I train this device). My success rate from a trial might be upwards of only 60%. New providers may be lucky to hit a success rate of 20%. (Don’t worry, with the right training, and with time, they get better). Not a day goes by where I don’t think about how I could improve my rate of treatment success.

I’d like to think savvy consumers shouldn’t be out there looking for a product, they should be searching for the person.

What actions does Australia need to take to improve equitable access to hearing ear and hearing healthcare for all?

Again, it’s not in my purview to suggest what Australia should do, but I can ask individuals what can they do? Are you the best audiologist you can be—in yourself—in your role in the company you work for?

10 years ago, virtually no audiology practice was doing micro-suction earwax removal. I worked for a large chain back then (a great job, by the way, loved it and the people). At the time, I considered safe, quick, gentle and effective wax removal essential for the audiology I wanted to do. I asked the company if we could get a machine. They said no, they wouldn’t a) finance the equipment, b) create whole new protocols and c) it wasn’t part of the ‘business model’ or . I get it. It’s hard to pivot in big business.

But guess what? I did it anyway. Solved every one of those problems myself. And somehow didn’t get fired.

Now, whole new small audiology business practices can pop up and sustain those early months just by providing and charging for that service. Nurses are quitting their jobs and creating businesses just for ear cleaning (I see this happening firsthand, as I assist with a wax training course). No offense to those go-getting nurses, but I see this, and I wonder: shouldn’t this be the domain of audiologists? What’s the point of our very expensive Masters degree with modules in pathology if we refer our patients to others, sometimes risking the potential dangers of syringing, to manage the very manageable inevitability of cerumen?

As a profession, we should strive to make point of contact a rounded and premium service (better practitioners/ clinic/ companies), and by the increased availability of points of contact (more practitioners/ clinic/ companies), we increase the opportunities for access (a more realistic goal than absolute equity).

And again, I hark on my theme: if we want to improve hearing healthcare services for others, should we not look directly into the mirror at ourselves (who, it must be said, are the only people we have any true sway with).

Looking into the future what changes do you hope to see?

From a clinical perspective: the word audiologist becoming synonymous with ear expertise (all performing wax removal/ the first point of call when a patient thinks ‘hmm, what’s up with my ears?’ To this end, we’d see a referral funding pathway shakeup, with some simple tweaks like the capacity for audiologists to refer directly to ENTS, and Medicare rebates for diagnostic audiology without the redundant GP referral (they do it for eye tests, why not ears?)

From a business perspective: I’d love to see a more savvy, empowered consumer base choosing from an array of small business owners. I know it’s scary out there. Vertical-integration (where a chain of clinics owns the product they sell) gives a profit advantage, and the buying power of some of these huge organisations means they can rapidly create new points of sale. But innate to large business is a general homogeneity to the service. There’s a lot of ears out there, attached to a lot of people, many crying out for intimate, personalised healthcare.

And, from a technological point of view, I’m really looking forward to some kind of advance in battery minimisation and efficiency, and then we can get a Lyric half its current size (the main reason I have to reject potential clients) with a 6 month battery life (we hover 2-3 months right now). Imagine a hearing aid we could insert and be worn 24/7 reliably for 6 months… Now, that’d be cool.

Any famous last words of wisdom?

Your life is not a dress rehearsal.

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