The Vocal Athlete and the companion workbook The Vocal Athlete: Application and Technique for the Hybrid Singer are written and designed to bridge the gap between the art of contemporary commercial music (CCM) singing and the science behind voice production in this ever-growing popular vocal style. These books are a must have for the speech pathologist, singing voice specialist, and vocal pedagogue. Continue reading
The Nature of Aural Rehabilitation by Raymond Hull, PhD, FASHA, FAAA
When my book, “Introduction to Aural Rehabilitation” was first published by Plural Publishing in 2010, I wanted everyone to read the first sentence. To me, it said it all. Those words are, “The aim of aural habilitative/rehabilitative services on behalf of those with impaired hearing is to overcome the handicap”. I felt that it was an all-encompassing statement that covered many aspects of the services that we offer on behalf of those with impaired hearing. However, it was a very general statement that left specifics unanswered. In the current second edition of “Introduction to Aural Rehabilitation”, I continue by saying, “The audiologist works with the patient to assist in remediating the handicapping effects of the hearing loss…to overcome the communicative, educational, social and psychological effects…that may result from impaired hearing”.
Now, the question that has plagued me and many of us during our careers as audiologists is, what do the specific elements of “remediation” actually involve? It is a subject that has been debated extensively over the years, and I have witnessed and been a part of those discussions. During my graduate studies, I was taught that what was in the book, “What People Say” by Ordman and Ralli contained many of the necessary ingredients for a successful program of aural rehabilitation. That approach, of course, has thankfully long passed into history. It seems that for nearly every person who provides services on behalf of individuals who possess impaired hearing, approach their habilitation/rehabilitation in ways in which they feel most comfortable. And, of course, that is appropriate since every audiologist deserves the opportunity to develop their own approaches to serving their patients, whether children or adults.
However, although audiologists generally have differing philosophies regarding the most effective and efficient avenues for serving their patients and assisting them to regain their place in their hearing/communicating worlds, it seems that there are common elements in the process that we all consider to be important in serving our patients. And, from those elements, variations on that theme provide fertile ground for individual approaches that generally take on many different characteristics, including those that I utilize and advocate in the second edition of “Introduction to Aural Rehabilitation” that I edited and share the authorship with other very talented authors.
First of all, the “list” of components that I feel are the most important in aural rehabilitation treatment continues to become shorter. But, even though the list has become shorter, I feel what is contained in that list has become more meaningful both for the patient and in relation to my own feelings that I am addressing the specific needs of the patient. Therefore, it is not a process that I feel somehow compelled to provide because it was “what I was taught in graduate school”.
The following is a description of the process that I advocate for working with adult who possess impaired hearing.
1. First of all, I ask the question that my primary care physician or my dentist or my dermatologist always asks me when I am seen by her. That is, “How are you doing? What can I do for you today?” Those are probably the most important questions that a doctor can ask their patient. And, if I have issues of concern, I tell her about those—a tooth that doesn’t feel well, and I point to its location. If I am seeing my dermatologist, I might say that I noticed a spot on my face and I want you to take a look at it, or for my primary care physician, my left knee has been giving me fits! In the situation involving audiologist and patient, the same questions are also appropriate. If the patient responds with, “Oh, nothing really. I can’t think of anything”. The patient’s spouse may fill in the gaps with, “Oh yes, there ARE problems!” And, we move on from there.
2. Most importantly, I listen to my patients as they tell me about difficulties they have in their own listening environments, and I take notes. I don’t want to hear replies in response to a pre-designed “communication profile”. I want them to tell me about their own listening environments and any difficulties they have in various situations where communication is intended to take place. I may give them prompts that involve typical places of hearing difficulty that I would like to hear about.
3.After my patient has given me a synopsis of why she or he has made the appointment to see me, and we have completed a case history, a thorough hearing evaluation is completed, particularly in regard to speech recognition since that is an important element in the patient’s real world of communication.
4. If warranted, depending upon the specific difficulties the patient is experiencing, appropriate amplification devices may be selected and fit as per the specific difficulties the patient is experiencing in her or his communicative life.
5. My patients and I talk about ways to improve upon their most difficult communicative environments. These usually center on home, job, social environments, church, and meetings. An environment in which the majority of my patients experience difficulty is that of their home, and may be specific to hearing and understanding their spouse or significant other. We talk about the acoustic environment that typical homes offer, since homes can be essentially anechoic chambers in which sound, particularly that of the sounds of speech, do not carry well.
So, above and beyond a hearing impairment, there are other reasons why it can be difficult to carry on a conversation in a home or other environment, particularly when one or both of those who are talking may not speak with the precision or clarity that enhances speech recognition. Hearing aids can certainly help, but they do not improve poor speakers!
6. If warranted and possible, I work with those who communicate most frequently with the patient on their speaking habits, including precision in articulation, voice production, and the use of appropriate suprasegmental aspects of speech. This is critically important on behalf of both adults and children with impaired hearing. My background in public speaking and interpersonal communication assist me in that aspect.
What I have written here is certainly not what I was taught in my graduate course in aural rehabilitation when I was a graduate student, and it is far from the prescribed course found in “What People Say”. But, I feel that what I am doing, and what I am advocating in my book, “Introduction to Aural Rehabilitation” is something that can truly help people, both children and adults, who possess impaired hearing in their personal, educational, occupational and social lives.
*Information on this topic can be found in Hull (2013) “Breaking News: Going Beyond the Basics in Aural Rehabilitation”. Hearing Journal, 66, 14-15.
Raymond H. Hull, PhD, CCCA & SP, Professor of Communication Sciences and Disorders, Audiology/Neurosciences
Department of Communication Sciences and Disorders
School of Health Sciences
College of Health Professions,
Wichita State University
Wichita, Kansas 67260—0075
Toward a More Effective Collaboration by Aaron Fletcher, MD
As a discipline Otolaryngology has long recognized the benefits and virtues of a collaborative model of healthcare delivery. In fact, I believe that few other medical specialties collaborate as frequently and as effectively as Otolaryngologists—it is an integral part of our culture. On a daily basis, we are called to collaborate with specialists of diverse expertise (Audiologists, Speech and Language Pathologists, Neurosurgeons, Radiologists, Radiation Oncologist, Medical Oncologists and so on). In consulting these experts, we recognize the knowledge of these specialists as complimentary to our own and no less valuable. In fact, we frequently congregate in multi-disciplinary conferences where everyone has a say, and everyone’s opinion counts.
As our specialty embarks upon a changing healthcare landscape, we are constantly challenged to evolve our collaborative process in order to keep pace with the expanding application of technology across healthcare.This collaborative spirit is one of the major reasons that I enjoy this specialty. One of the things I appreciate most about Otolaryngology is the opportunity to learn the subtle nuances of a diagnostic finding, condition or technique that are afforded by colleagues and other members of the treatment team. Throughout my very young career, I’ve found that better collaboration invariably leads to better care and that to be successful; collaboration requires shared vision, values, risks, resources, and rewards regardless of function, occupation or level of training. This is truly what collaborative care is all about.
The ubiquity of internet access via mobile devices and smartphones, along with the rise of social media has changed the way in which health care information is distributed and consumed. This factor has allowed patients ample access to information about their health conditions and associated treatment options. A recent Pew Internet research study found that one in three adults have turned to online sources to figure out a medical condition that they or someone else they know might have1. Combining these internet resources with expanded mobile network technology means that patients are increasingly capable of seeking answers to their healthcare questions instantaneously. This means that patients are now empowered to become more active participants in their care, and this is certainly a good thing.
On the other hand, these factors also exert pressure upon caregivers to keep pace with these changes in health related information consumption by increasing technological sophistication and improving their own access to medical knowledge. By doing so, we are better suited to meet the demands of a patient population that is better equipped to make important healthcare
As the application of technology across the healthcare landscape has led to a greater sense of empowerment among patients, advancements in health IT, (including electronic health records, cloud computing and health information exchange platforms), also hold great promise for clinicians. The advent of these tools has empowered clinicians to mobilize and share clinical information with members of the treatment team at any time and from any location with internet access. Given the intrinsic collaborative nature of our field, it makes perfect sense that we leverage these technologies to expand our approach to coordinating collaborative care. HIPPA compliant hosting and file sharing networks are now working to mitigate the risk of exchanging protected health information (PHI) via the web and mobile devices. These networks work to encrypt PHI both in storage and in-transit, thereby providing a layer of protection against breaches in security. While these platforms should be used with caution to ensure compliance with HIPPA regulations, as these tools continue to evolve, they will create new opportunities for collaboration and partnership across traditional institutional and geographic boundaries.
Naturally, I believe that Otolaryngologists should be at the forefront of integrating these tools into clinical practice, as we continue to seek new ways of perfecting collaborative care. I believe ubiquitous data accessibility and sharing (cloud computing) coupled with HIPPA-compliant hosting platforms have the ability not only to facilitate, but to enhance the way we collaborate. Using these tools we can share best practices and treatment protocols, coordinate video conferences with colleagues outside our geographic area, and obtain outside expertise about challenging cases. These tools also allow us to interface with patients about their care, and to provide them a portal to share relevant updates on their condition from the comfort of their home. All of these efforts are critical to the long-term success of our collaborative efforts as a specialty, and familiarity with the tools by which we accomplish these aims is imperative.
So as we embark upon a continually evolving paradigm of healthcare consumption and delivery, we must continue in the spirit of collaboration, and seek out the new tools of our trade. By doing so, we can continue to demonstrate that better collaboration leads to better care.
1. Fox, Susannah, Duggan, Maeve: Health Online 2013. Accessed online via http:// pewinternet.org/Reports/2013/Health-online.aspx
Dr. Fletcher is the author of the just-published Comprehensive Otolaryngology Review: A Case-Based Approach
By Usama Hamdan, MD, FICS
The quest for optimal outcomes in patient care is a driving force for healthcare professionals. This is especially true for those caring for patients born with clefts. The significant advances in medicine coupled with the logarithmic expansion of information dissemination have facilitated the sharing of knowledge throughout the globe. Video Atlas of Cleft Lip and Palate Surgery edited by Derek Rogers, MD, Christopher Hartnick, MD and Usama Hamdan, MD, FICS presents both in print and videography the knowledge, understanding, philosophy and skills of various multi-specialty cleft experts in an attempt to unravel many of the questions regarding cleft management with particular emphasis on surgical techniques.
The disparity in surgical outcomes, lack of comprehensive care and lack of the concept of cleft team methodology are quite striking but understandable under certain conditions that might be attributed to the deficiency of resources throughout many parts of the world. However, in other regions or capitals where resources are available, comprehensive cleft care is also absent or scarce. A multidisciplinary team approach is essential for rendering the best possible cleft care.
This book aims at sharing the vast practical experience of the authors with readers from various specialties, enhancing the dissemination of training at a global level, an option made possible through the expansion of internet and online teaching, and hopefully be a catalyst for the development of comprehensive cleft programs worldwide. Coupled with the power of video documentation, the book also hopes to enhance the ability of the reader to capture the step-by-step surgical techniques that have been useful in the hands of the authors in reproducing successful outcomes.
Preclinical Speech Science: A Cool Stroll through the Forest
by Gary Weismer & Jeannette Hoit
Every discipline has its “trial by fire” entry-level courses; in the field of speech-language pathology, the speech science course is one of those. Students often see speech science as a walk across the hot coals of anatomy, physiology, and acoustic output of the speech apparatus. Our view is that it should be more like a stroll through a beautiful forest, with vegetation and wildlife that is so interesting you can’t help but stop and admire it, ooh and ah over the relationship between structure and function of a plant here, an animal there, and want to remember the details of this new and intricate world because you just know that understanding it will be useful to you in the future.
There have been many great speech science textbooks over the years, and almost certainly many more to come. When we set out to write the first edition of Preclinical Speech Science: Anatomy, Physiology, Acoustics, Perception, we asked ourselves the question, ‘Why write yet another speech science text?’ Our answer was that we wanted to 1) present the kind of beautiful images, coordinated with easy-to-read, straightforward text, that would make students want to stroll, stopping frequently, through this beautiful forest of knowledge that is the back country of speech-language pathology, 2) expand greatly on the ‘other A&P’ (Acoustics and Perception), 3) update the speech physiology to include contemporary notions about how speech production works, and why it has clear relevance to the speech-language pathologist’s daily practice, 4) include examples of clinical applications of speech science in the forms of clinical scenarios and sidetracks, and 5) integrate the fundamentals of the anatomy and physiology of human swallowing, a knowledge base that has become increasingly important over the years in the training of speech-language pathologists. We also wanted an accompanying workbook that would contain problems ranging from the easy, memorization type to those requiring a fair amount of thought.
But every rose has its missing petals, as did ours, which even those who admired our text were quick to point out. Our missing petal was a chapter on the brain. The National Institutes of Health (NIH), in coordination with other government agencies, had identified the period between 1990 and 2000 as “The Decade of the Brain,” and indeed during those ten years there was an explosion of research on the relationships among neuroanatomy, neurophysiology, brain lesions in a host of diseases, and behavior. This explosion was heard throughout the speech science world as well, and continues to resonate with speech-language professionals to the present day. The brain processes underlying speech and language behavior, both normal and impaired,
are under heavy scientific and clinical scrutiny and speech-language pathologists need to be well-versed in this area. With an ever-increasing aging population and its associated neurogenic diseases and their potential to affect speech-language behaviors, most training programs are putting added emphasis on a deep understanding of brain structures and mechanisms as they relate to communication. So in our second edition of Preclinical Speech Science, we have tried to enhance the rose with a new petal—a full chapter devoted to neuroanatomy, neurophysiology, and brain processes and models specific to speech production and perception. In preparing this chapter, we retained our devotion to high quality images and patient, comprehensive text to make those images relevant and highly accessible as a new source of knowledge for the student. We also showed how contemporary models of brain function in speech production are relevant to the diagnosis and management of disorders such as dysarthria and apraxia of speech.
In our writing of the new edition of Preclinical Speech Science, we have also updated much of the information in the original chapters, fixed mistakes, and prepared a new workbook to accompany it. We urge you to give it a try, stop to smell the anatomical, physiological, acoustic and perceptual roses in the forest. If you allow your eyes to linger for a while on the wonderful images drawn by Maury Aaseng and think about what’s written in the text, we think you’ll find the ground less like a bed of coals and more like a cool stroll. And your knowledge of all things speech science will make you cool in the eyes of your fellow health care professionals!
Why Quality Matters: The Changing Healthcare Delivery Model
By Brian Taylor, AuD
In fits and starts, physicians and other healthcare professionals are beginning to realize that the convergence of wireless sensors, social networking, mobile connectivity and robust data management systems will profoundly impact the future. This transformation of medicine is likely to put a premium on healthcare professionals that place the patient firmly in the center of the clinical experience. These same forces will undoubtedly affect audiologists and their support staffs, and quality is likely to be a key differentiator in a disruptive future.
In this new world, physicians and other healthcare professionals are more likely to be reimbursed for the quality of their results, rather than the sheer number of procedures they order. Hospitals and clinics that demonstrate higher-than-average patient satisfaction scores will enjoy higher rates of reimbursement from federally funded programs. Patients are even joining the quality bandwagon as many are demanding greater transparency when shopping for medical services. In essence, patients are demanding to be treated more like customers. Consumer-centered health care is gradually supplanting the antiquated, paternalistic model in which the practitioner is never questioned and has near omnipotent authority over the uninformed patient. Out of this paradigm shift comes the quality movement. For audiologists this means the use of report cards, key performance indicators, and other quality strategies and tactics, if they want to stay relevant in a highly competitive marketplace. If you are like the typical practitioner, there is a good chance these concepts related to quality sound a little strange to you now. This is why I wrote Quality in Audiology: Design and Implementation of the Patient Experience, to help you prepare for some of these changes.
Interestingly, hearing aid manufacturers are very familiar with many of these concepts. In an effort to rise above their fierce competition, manufacturers have been obligated to standardize quality within their production lines by using tools such as Six Sigma and Total Quality Management. At the heart of these quality tools is a drive to eliminate variance. Eliminating variance is a worthy goal for the optimization of medical devices, but clinicians know all-too-well that each patient has built-in variability. Thus, many of the quality concepts and tools device manufacturers have come to rely on to incrementally improve quality don’t work well with patients. This paradox of quality within healthcare, as the book suggests, can be overcome through the standardization of quality around six patient staging areas.
The purpose of this book is to bring a level of practicality to the implementation of quality within an audiology clinic. As the book proposes, quality is improved mainly through your grassroots initiatives: procedures, programs, and behaviors you implement, measure, and manage in your clinic. This grassroots perspective requires audiologists and other professionals associated with hearing heath care to reexamine the concept of quality. According to the International Standards Organization, which acts as a sort of quality police for device manufactures, quality is the totality of characteristics, including people, processes, products environments, standards, and learning, of an entity that bear upon its ability to satisfy stated and implied needs. This definition suggests we improve ourselves and our ability to create quality in the world around us through innovation and the judicious use of best practice standards.
From a workaday, clinical standpoint, quality is meeting the requirements and expectations of patients and stakeholders in the business. In short, quality is probably best defined as the standardization of individual excellence. Rather than rely on academic boards and government agencies, the quest for better quality begins with self-motivated and dedicated audiologists and support staff who can use data to make better decisions about their patients. Quality in Audiology will get you on the path to continuous improvement in your clinic.
By Seilesh Babu, M.D., Michigan Ear Institute
Hearing loss is one of the most common conditions affecting otology patients whether as a newborn or aging patient. Hearing loss can significantly impact one’s ability to communicate leading to reduced quality of life, isolation, and even depression. Seeking medical help to assist with this hearing loss can be the biggest obstacle for many patients who do not want to acknowledge a hearing issue. However, if the problem is properly managed with hearing aid assistance or surgical therapy, improvement in the patient’s quality of life including anxiety, depression, frustration, and social isolation will be positively impacted.
In our practice at the Michigan Ear Institute, we see thousands of patients annually with hearing loss concerns in all age groups. Some of unilateral hearing loss and many have bilateral hearing loss, ranging from mild to profound. Unilateral hearing loss can be caused by not having an ear canal form (canal atresia) or, from nerve damage of unknown etiology. These patients have several options to improve their hearing such as using CROS hearing aids, bone anchored devices, dental implanted devices, or surgical repair of the poorly formed ear canal in the case of atresia. Many patients have significant improvement in their hearing in various situations using these technologies and surgeries.
Recently, a patient of ours received a scholarship from Cochlear Americas, the global leader in implantable hearing solutions. This scholarship recognizes bone anchored device and cochlear implant recipients who have shown academic accomplishments as well as a commitment to leadership and humanity. Using the technology of hearing devices, patients are able to complete advanced academic pursuits despite having hearing impairment that may have proven to be an obstacle. We are proud to be a part of this successful path for this patient who is currently enrolled in a Ph.D. program.
Hearing technology continues to improve. Advances in hearing aids have occurred with smaller, more powerful processors and noise canceling technology, as well as masking technology that treats tinnitus or ringing in the ear. Middle ear implants provide a surgical treatment option for patients who do not want to wear conventional hearing aids. Cochlear implantation has revolutionized the ability to treat patients with complete hearing loss either as a newborn or for patients in their 80s.
Children born with complete deafness are able to be treated with a cochlear implant with near normal function from speech and language development to academic performance. Adults with late onset profound hearing loss are also able to obtain a cochlear implant in order to maintain excellent quality of life, independence, and social interactions. Some elderly patients diagnosed with Alzheimer’s disease may in fact be suffering from severe hearing loss that needs to be diagnosed and managed.
In the future, advances in stem cell development and treatments will improve the quality of life of hearing loss sufferers. In addition to these new technologies, it is the collaborative effort of otologists, audiologists, and speech-language pathologists in treating patients with hearing loss that continues to have a positive impact in the lives of these patients every day.