us through the topic of implementing tinnitus care is speaker John Hoagland. John Hoagland, ACA BCHIS founded Hoagland Family Hearing and Audiology Center as well as Southwest Florida Tinnitus and Hearing Center, large multi-office practices with a family feel. John has a passion for helping individuals suffering from tinnitus and helping hearing health care professionals get involved with tinnitus care. He holds a tinnitus care provider certificate from the International Hearing Society and was a member of the founding committee of IHS's tinnitus care provider certificate program. He has published several articles and given talks at the regional, national, and international level on the topic of tinnitus care. Take it away, John. Hello, everybody. So I'd like to, I am proud to be part of this particular session. It is something that I am very passionate about and I'd like to do a shout out to all of the IHS people who have helped put this wonderful conference together. I've met a lot of CHIPS members at various different functions I've attended and I've also really appreciated and really enjoyed the first two speakers. Dr. Brogan and Dr. Beck put on a marvelous presentation and I hope to get your thought process going towards other ways that you can differentiate your practice. Now, as mentioned, I own Hoagland Family Hearing and Audiology Center with my lovely wife, Patricia, and we have been a blended practice. So we have had audiology and hearing instrument specialists with us and that made our foray into the field of tinnitus a little less scary because we had a little more local knowledge. I learned a lot from some marvelous audiologists about this and eventually we opened Southwest Florida Tinnitus and Hearing Center. Now, the tinnitus versus tinnitus, all the patients say tinnitus, all the clinicians say tinnitus, so I tend to morph between the two. In fact, we answer it, the phone, tinnitus and hearing center. But this, once you hang a tinnitus shingle, there is a tremendous difference in the people that you see and I had no idea how many people were searching for answers and searching for help and searching for hope. I wrote a few articles about this for the Hearing Professional and then we got pow-wowing together and I was very honored to be part of the committee that established this program and got to work with Dr. Richard Tyler directly and he changed my life in many, many ways. Why might you want to get involved with tinnitus care? Well, more people experience tinnitus than experience hearing loss, so you have a much, much larger audience to talk to and that always struck me. Here in the States, there was roughly that 36 to 38 million people who suffer with hearing loss and 50 million who suffer with tinnitus. From what I could see from the Canadian numbers, there was anywhere from 3 million to 5 million people with hearing loss, but there was 9.2 million with tinnitus. Roughly 40 percent of Canadians suffer this problem. So, there is now a broader audience for you. Now, more people will admit tinnitus and deny hearing loss. I mean, we've never heard anybody deny their hearing loss, right? So, they will come in and they will openly tell you about their tinnitus problems. And so, you will see people that you wouldn't have seen in your practice. In fact, the comment down below was actually from a prospect in our local community. It says, you mail me three letters a year about hearing aids and I throw them in the trash, but when you sent this letter concerning ringing ears, I had to come and talk to you. And of course, he needed hearing aids and purchased hearing aids and later became a referral source for other people with tinnitus and other people who needed and purchased hearing aids. So, people you will find will be more motivated to address their tinnitus relief than are motivated to improve their hearing. I noted that when our first speaker was speaking, Dr. Brogan mentioned the fact that as you are doing oral rehabilitation, which will differentiate your practice, and you start to get into some cognitive things, how do you bring up cognitive screening? Well, she said people were more concerned about their memory help than they were about their hearing help. Well, trust me when I say people are more concerned in some cases about making this noise in my head go away than they are about communicating with their loved ones. I used to tease couples. It was stereotypical, especially if the male worked in a noisy environment his life or was a veteran, etc. And the wife was very, very delighted that she was able to communicate with a veteran. He could hear and understand his family and participate more in life, but he was just happy to have that noise in his head go down or go away. So, you're going to see people that you wouldn't have seen, and this will make your practice more successful. Now, the other reasons you want to do this, in my opinion, we all see people with tinnitus. I mean, from my very first week in the field, I ran into people who suffered with tinnitus problems. So, giving you more confidence and more competence in working with these hearing aid patients that also have tinnitus will do nothing but improve your relationships with them, and that feeling of confidence can't be understated. People can sense that, hey, this is a topic you know about. You understand where I'm coming from. It dramatically increases your referral networks, if you do this right. You know, in Florida, there is a hearing center on every corner, and trying to get primary care to dispense to you, unless you're in their building or something, was very challenging. They all had their own referral pattern, some referring to big box warehouses, save a few bucks, but none of them truly had a place to refer their tinnitus patients, and they would do the unfortunate thing of saying, from what I understand, nothing can be done for tinnitus, and give people who desperately needed help and hope no hope. So, getting the word out to them, and there are strategies that you will be taught in this class that will lead to that, increasing your revenue from tinnitus-related products. You have to have a good battery of noise protection devices. You know, it is amazing to me, to this day, that gentlemen, in particular, with screaming tinnitus, won't think twice about jumping on a riding lawnmower with no ear protection. And the silly, ridiculous thing I've always heard is, what's the point, John? The damage is already done. Well, the way I would phrase that to them is, I say, somebody who has a tinnitus problem should be as obsessed about avoiding future noise as someone who has sun-induced skin cancer has to be obsessed about the sun's harmful rays, because the sun will affect that person differently for the rest of their life, and noise will affect you differently for the rest of your life. But the respect within the professional community, and I mean people in my chamber of commerce, down to people in the local fraternal organizations, and Lions, and Rotaries, and everything, as well as everyone in the medical community, when they know that you are somebody that may be able to help their friends, they will beat a path to your door. So, how do we present this? Because patient after patient said, I'm going to tell you right up front, I went to three people about this before, and all they wanted to do was sell me some hearing aids. And although that might have been the solution, it was in the presentation. And that is what we need to do in advance. We need to take the time to explain the cause-effect relationship between especially noise-induced hearing loss and ringing ears. You have to be able to do it. So, right up front, we go through the technical definition. Well, it's an auditory phantom perception. It's an auditory sensation not related to the perception of sound. It's the conscious experience of sound that originates in the head, and their eyes would roll back in their head. So, that doesn't really give them the speak-at-my-level definitions, but tying it into something many have heard about, phantom limb syndrome, sets the table correctly. So, phantom limb, for those who aren't familiar with it, it doesn't happen to somebody who was born without an arm or a leg. It is someone who had a fully functioning arm or leg their entire life. An accident occurs. They lose the arm below the elbow, they lose the leg below the knee, but the brain remembers all the years it was there, and they distinctly feel that their hand is birdy or itchy. Their foot is throbbing. I can't sleep tonight. My foot's on fire. And they don't even have a foot. That's phantom limb. In a similar vein, your brain used to hear every single pitch of sound. When there's damage to a given pitch, and the brain no longer hears that sound, it misses it. And internally, it begins to create the sound that, in essence, it is now craving. So, you will learn to do it in the tinnitus care provider class. You would learn to do additional testing procedures. One of them finds the pitch of the noise in their head. And we find so often the pitch of the noise in their head is the exact pitch of the tinnitus. So, that is where the greatest hearing loss comes in. So, someone who has a drop at 4,000 may find just before it drops at three or at four is the exact pitch of the noise in their head. And sometimes, as we all know, it's been easy, and we get very lucky, and we kill two birds with one stone, that when we give them back the sound they need in order to communicate, the brain says, oh, that sound is back. I don't need to make it any longer. And sometimes, we get really lucky and kill two birds with one stone, that all we had to do is solve the underlying communication problem, and we've mitigated the hearing, the tinnitus problem as well. Other cases aren't that easy, and you need advanced skills. Sometimes people get a slight relief when they begin wearing the hearing aids. They may grow over time. Some people, they only get the relief while they're wearing their hearing aids, and after they take them off, it returns. But sometimes over time, it returns an hour after they take them off, three hours after they take them off. So, but giving the brain the sound that it needs on an ongoing basis is really the necessary item to reduce and eliminate this for them in many cases. So, I say there's three legs of the tinnitus stool. The first is the tinnitus sound itself. Some hear a ring, some hear a buzz, some hear noises, other noises in their head, steam escaping, locomotive, high pitch whistles, etc., etc. So, the sound itself does dictate the treatment in some cases, and we'll get into that with cases like pulsatile tinnitus. How much that sound draws their attention is huge, and that is variable, and it isn't based on the degree of volume. Two people could have the exact same noise in their head. One of them just finds a way to stay busy and doesn't pay attention to it at all, and the other, it's all they can do is focus and dwell on it. So, that is important. And then lastly, how much stress or distress this brings to their life. And trust me, there are people that the tinnitus is a major debilitating aspect of their life. When people come in to see you, they fall into three basic categories. We have the curious. Hey, there's this buzzing going on in my head, and I was wondering what you could tell me about it. Well, in those cases, we offer basic information, but we also try to get a hearing test. Yeah, my whole life I have said every human being needs to have a baseline hearing test in their medical records, and I've always been the provider of that. But I used to always tell my staff, don't ever try selling hearing aids in the lobby. All you want to do is create enough interest to sit down and talk to them. Because as we know, sometimes single-sided tinnitus could be wax paper pressed against the eardrum. And if they don't sit in your exam room and let you inspect their ear, you can't tell them that very simple solution. So, always try to do that. Now, there are some that go beyond just curious. And now I'm concerned about this. This is really starting to bother me. And you know what? I am not sleeping the way that I should. So, you want to do basic information, you want to do a hearing test, and you want to get into various treatment options with that patient. And then there is the very distressed. Now, many of you haven't seen them, because they don't typically come and see us. But if you do happen to mention that you are a tinnitus care provider, you will see people that are very, very, very distressed. So, you offer counseling to those people. In addition, you offer sound therapy for them. And we'll get into that a little bit. And you offer professional referrals to people who are really beyond the normal reaction to their tinnitus. So, when you're determining the degree of their tinnitus distress, there's different forms and different tools in our toolbox. Their comprehensive case history gets even more comprehensive, finding out different things about the types of noises they've been exposed to, the types of medication, head and neck injury, things that we may not generally ask. We use the tinnitus reaction questionnaire with every patient and the tinnitus history questionnaire with every patient. But there's also the tinnitus functional index. I'm also a big proponent of the spousal tinnitus hearing questionnaires. So, it's always been a part of my practice that I ask the patient what they're experiencing with their hearing loss, but in a separate form to be done in private with no coercion that the spouse does about the hearing problems. I do the same with the tinnitus. And the man, just like he says, there's nothing wrong with me, there's nothing wrong with me. And she says, he can't hear, the TV is blaring, et cetera, et cetera. Same thing. No, it's no big deal. She says, honey, there are times I see you get up three, four, five times a night. You're snappy. I can tell when your ears are ringing and they will open up and that's critical. Dr. Richard Tyler, who teaches the class, works at the University of Iowa and the Iowa tinnitus handicapping questionnaires and the Iowa tinnitus activities questionnaires are big with him. But there's the tinnitus handicapping inventory, the tinnitus functional index, the tinnitus severity index. There's a lot of tools to be used out there. Finding what works for your practice and then mastering it is really the key to success. But I'm going to cover the two that we do, the TRQ and the THQ. So in the tinnitus reaction questionnaire, you're finding out how much this bugs them on a daily basis and how much it influences their life. And this is a zero to four points on 26 questions. So a maximum score on this is 104 points. And we have had a number of people that sadly have answered full up to 104. And where you go with how you take care of this person and where you go on where you feel comfortable taking care of these people can be a numerical value. We have people that are earlier on in their tinnitus care that anything from 25 and under, they feel adequate to take care of and know what they're doing. But if they get beyond that, we'll refer out to another team member or another referral source within our community. But some of the questions, my tinnitus has led me to avoid quiet situations. Tinnitus, silence is the tinnitus playground. And I'll explain more about what I mean in that. My tinnitus has led me to avoid noisy situations. Some people will tell me they'll go to a noisy restaurant and just the din of the restaurant or one man said to me exactly that he went with his big family gathering and he didn't realize when they sat down to dinner, but there was a band setting up to play behind him and they did and they were loud. Well, he had already ordered his food before he realized this. He didn't want to inconvenience the waiter, et cetera, et cetera. So he just sat there and took it and it took him five, six weeks till his ears quieted down. Now we teach our patients to have noise protection with them, have it in your wife's purse, have it in your glove box, have it in your luggage for when you travel, et cetera, et cetera. So I had that man said, Ooh, there's a band here. I better go get some ear protection, walk to the car, pull those earplugs out of his glove box and put them in. Six weeks of agony could have been averted by that. And you can still talk through those as you've probably noticed yourself. My tinnitus has interfered with my sleep. Sleep deprivation is an extremely, extremely significant aspect of tinnitus distress. The people that fall into distress are the ones that it's influencing their sleep. If you don't sleep, nothing else works. And my tinnitus has led me to think about suicide. Many of you may have never had anybody openly tell you this in the past. If you are a tinnitus care provider, you may see that on a much more frequent basis. And in some of them are only a one, but some of them are almost all of the time. And you have to have a referral network that you refer to. It's a small percentage of what you see. But when you see them, you have to know exactly what to do. And you'll learn that in this class quite well. Now, the tinnitus distress and the degree of distress can also be measured with the tinnitus history question. And this gets more involved and lets people tell you more essays. And I would say whatever words they use, echo back and read through this one thoroughly with them and get a balance. And I'll point out a couple of things I think are important here. My tinnitus is worse in my left ear or worse in my right. Well, single-sided tinnitus raises red flags, especially if it's unexplained. Okay. By unexplained versus explained. A guy says, I was on a shooting range with my buddy. And just as I pulled off my ear protection, he pulled the trigger. My right ear has been ringing ever since. I was in an auto accident. My head hit the driver's side and my left ear has been ringing. That's explained single-sided. But when it's single-sided and it's unexplained, one of my early mentors, Dr. J. McSpaden, early in my career, used to pound his cane on the ground and say, that is an acoustic neuroma unless proven otherwise. So the referrals that we would do to rule that out have to be there. Now, who have you consulted about your tinnitus is an important one. You want to know who they've been talking to, and you want to get records releases from the previous testing. This again, starts you in interacting with other people and working with other clinicians and providers, and you know what happened. And you may see from the prior tests where they really didn't have tinnitus in their right ear. To this test, there's a massive change. Or when I saw this guy, it was a very, very mild problem to me. When I saw this guy, when I see you today, it's a big problem to me. Well, in that time, the hearing in only one side has been changing. So it could be Meniere's, it could be an acoustic neuroma, but you want to rule out any of those things. Have you attended gunfire, explosion, any loud, noisy jobs, things like that, all your general hearing problems. Now, when you're asking the questions about the hearing, most patients are completely unaware how hearing loss and tinnitus distress are related. They just don't get it. And then at the very end here, we rank them. So between hearing loss, tinnitus, and sensitivity to loud noises, what's your number one concern? What's number two? What's number three? So if the sensitivity is there, it may indicate hyperacusis, which is discussed in a great deal in Dr. Tyler's class, but time doesn't permit adding that topic to today's lecture, but you want to know. But it will also tell you their attitude about addressing hearing loss. So they may put a one or even stars all over tinnitus and hearing loss, they'll draw that big circle with a line through it. Like, I don't care about this at all. But you got to know where you stand with that. You don't want to get into it. You want to lead the witness through education into understanding that no, there is no magic silver bullet that will solve this if you don't address the underlying hearing loss. But it gives you a tool to give you where's my head today. So over the past week, what percent of the time you were awake were you aware of your tinnitus? And what percent of that time was it disturbing? Does your tinnitus prevent you from going to sleep? And sleep deprivation is a big topic to discuss in depth. And I didn't have near the skills in dealing with people with sleep deprivation in advance as I did after working with Dr. Tyler. Are you taking any medications? You've got to know all the ototoxic medicines. You have to know all the things that can contribute. Now the cancer drugs can. And you know what? You got to beat the cancer. So there's no getting around that. Somebody coming out of a hospital having major surgery with the heavy duty pain medications, your Percocet, your Darvocet, your oxycodone. But even the over-the-counter ones can contribute. Now don't worry about the baby aspirin. You know, I had a gentleman who had had three bypass surgeries and five stents who stopped taking the low dose baby aspirin that was probably keeping him alive because his neighbor had told him that aspirin can make you really sick. Don't worry about that. But the person with the knee injury, the neck injury, the hip replacement that takes a couple in the morning, takes a couple before lunch, takes a couple before dinner, takes a couple before. And this could be your set of medicines, your ibuprofen, any of the analgesic. All of those can contribute to that. And you want to get the medical details, the contact details of not only their ENT and who they've gone to, but also their GP. Because when you start sending reports to GPs and you ask them to sign a release, you can get their previous records, as I mentioned earlier. But more importantly, you can start sending records out to people that I saw your patient for this, and this is what we're doing. And when the doctors start seeing these come across, specifically if the doctor opens the record and says, hey, by the way, I hear you went to somebody for your tinnitus, if they give you flattering responses and they heap praise on you, the next time they have someone, and trust me, they'll see a lot of them, the next time somebody mentions ringing ears, they're going to start sending people your way. Well, when they start to get the third, the fourth, the fifth, the 10th person, now you've got an ongoing referral network, and that's huge for your practice. So for most patients, tinnitus is a non-threatening symptom, but there are cases where referrals are recommended and you need to establish a referral network that has the following disciplines. You have to have an ENT that you can refer to. You have to have local audiologists if your practice doesn't have one, and psychologists and psychiatrists. Now, with the ENTs and the audiologists, it was interesting to see Dr. Beck, when he was throwing out all of his articles, one that he wrote, I think 2020, he was still talking about turf wars. I understand it's not as big a deal in Canada. I understand that you guys get along much better, especially the audiologists and the HIS. In the States, there have been, I've gone through 40 years of watching these turf wars, you know, and scope of practice and trying to restrict people, and they're the enemy. And I've always maintained, we're colleagues, not competitors. It's all of us versus hearing loss, and we got to get on the same team. And I've always tried to maintain a good relationship, but you need at least one otolaryngologist that you have a good relationship, and one audiologist that you have a good relationship with. And the psychiatrist and psychologist, or what we refer to as tinnitus coaches, can help people specifically dealing with the emotional baggage that comes with this. And I'll discuss this in more length later. Single-sided tinnitus, especially if unexplained, send it out. Asymmetrical hearing loss that has never visited an ENT. Let's rule that out. Meniere's patients who haven't seen an ENT. So Meniere's will typically have more of a low-roaring tinnitus, oftentimes asymmetrical hearing loss, and a vertigo component is present. And if they haven't visited an ENT, they need to. And patients who are highly distressed, psychologists and psychiatrists, and cognitive behavioral therapy, and help them dealing with their reaction to the tinnitus is big. And if a patient opens up to you that they have thought about self-harm, you have to have some people. You don't want to then open the yellow pages for the first time, or Google who takes care of these people. You want to establish this in advance. And how to do that is a big portion of the tinnitus care provider class. If a patient presents with pulsatile tinnitus. So pulsatile will go kind of like a thumping, and it's in time with their heartbeat. Sometimes I'll ask them, if you jog or if you were to do something aerobic, does it speed up? Well, that can sometimes be something that can be a clogged artery in the area near the ear, or it could be that there's a growth or fluid in the ear that makes them hear their heartbeat. So you have to have referral for that. Unilateral tinnitus, as we've mentioned before, that is unexplained in particular. You're paying in drainage, you're probably referring out anyway. Head and neck movement. Sometimes if I move my head a certain way and hold it just like this, my ears will ring. Well, first of all, don't do that. You know, doc, it hurts if I go like this. Well, don't go like this. But it could be that there's something in the cervical area that needs to be addressed. Vestibular symptoms, again, with the dizziness component. TMJ, sometimes they hear more of a clicking, and because the jaw is right next to the ear, they think it's coming from the ear, and it could be somebody that really needs a good dentist. And severe hyperacusis, which is covered in the class, and misophonia, that's the people that the smacking of the gum really, really bothers them. Somebody clicking a pen really, really bothers them. Those are people that also need to be referred. That's almost in the compulsive area. Now, when you learn this class, you'll learn to do things they haven't seen other places. You know, just as our first two speakers, Dr. Brogan and Dr. Beck mentioned. You know, if you do oral rehabilitation and nobody else does, you've separated yourself. If you do speech and noise testing and nobody else does, you've separated yourself. If you have some kind of cognitive component and nobody else does, you separate yourself. If you know and do things in the tinnitus field that nobody else does, you will, again, separate yourself. And I saw the question about scope of practice, and I started thinking, and I really think there is the legal thing, and I am not going to minimize the legal thing, but I always tell people, increase your scope of knowledge, no more than anybody else, or no more than you did yesterday. Constantly strive to increase your learning and your understanding of every way to help people, and can increase your scope of contribution to society. And I always say, we don't hang widgets on, so we don't sell widgets, we change lives. And changing lives, as the first two speakers mentioned, following their guidelines will be helpful. And here, you're doing things, you have to open a very closed mind. I do not want hearing aids, but they need hearing aids. And how to help them is done through some of these additional tests. So pitch matching. So instead of the beeping sound, we will now give them a pure tone. Boo, boo, boo. And we will go up and down, back and forth, using a bracketing method, meaning I will present it at 250, I will present it at 1,000, I will present it at 4,000. Which one of these, when my noise sounds closest to the noise in your head, let me know. Now you have to do a lot of clarifying, because some of you, is that what your tone sounds like? No, yours is more of a boo, boo, boo. And I hear steam escaping. Okay, okay, it's the pitch of the steam escaping. So you have to find a way to get them to understand pitch. And I talk about notes on a piano, from boom, boom, boom, bing, bing, bing, ding, ding, ding. So now let's say they chose four. Well, the next bracketing would be 2,000, 4,000, and 8,000. And they choose four. Now we do 6,000, 4,000, and 3,000. This time they choose six. We do four, six, and eight. They again choose six. So eventually you're gonna find the pitch of it. And you'll look back at the audiogram. Turn the audiogram behind. See this one here at 6,000, which is the worst hearing you have. And you underline it. That's the pitch of your tonight. See this pitch at 4,000? That's the pitch. Now, sometimes when there's that big fall off a cliff, drop between tones, it might be that it is really, the worst is three, but they sense it at two. And sometimes it's hard to pin exactly. But when you try, that's something they haven't seen before. And now when you showed them the phantom limb syndrome information in advance, and now it turns out to be exactly that, it helps. Now the loudness matching, that's another new test for people. So once you've established this sound, you will raise the volume in each ear independently until you get to the volume where my sound is as loud as your sound. And I'll do it in the other. Well, let's say for a simplistic one, at 3K, at 70 decibels is where it matches. Now, patient's family are a key to getting the help, but it's a key for the patient to get the support they need as well. Because most people, unfortunately, a lot of tinnitus patients have not been treated well by those around them. You know, like, oh, get over it. Oh, it's, how bad could it be? So I take the headset and I'll turn it on 3K at 70, and I'll put the, you just have to put the earphones close to the spouse's ear and say, this is the noise he's hearing in his head. This is what it sounds like. Oh my God, I can't believe this. So that's there. And the minimum masking level, that determines how loud you will have to turn your masker. So let me know when this sound is loud enough where my sound drowns out your sound. Now, these measurements validate their experience. They explain the relationship between hearing loss and tinnitus, and they guide in setting the masking stimulus, and they assist in the counseling, and it separates your practice for others. The reactions, again, your thoughts and emotions, there's sleep, there's hearing, and there's concentration. And the tinnitus activities therapy that Dr. Tyler teaches has a separate module for each of these. And a complete patient plan addresses all of these categories, but you don't have to. They're independent. Each of these four categories are totally separate. Tinnitus activities therapy uses picture-based counseling and has advantagement in the matching. The sessions proceed in a very orderly fashion. You do not overlook important concepts. You follow right through. It's easier for the patient to understand these concepts. Pictures help a lot because someone who is hearing impaired is visually stimulated. The plan can be used by other clinicians. If you're out one day and somebody comes in and they're taking your schedule, they know what page you're on in the process. It's really helpful. And again, you can adapt it to just the things that are important to those people. So the patient's responses vary very, very widely. So the amygdala is the part in the brain that triggers the fight or flight response, or how important should I treat this? And look where it is in relationship with the ear, which is very interesting. But the limbic system, that's our fight or flight. So the exact same sound will be totally different response. We teach people how significantly their thoughts and emotions can influence the tinnitus. So it's one of the few conditions that gets worse just by thinking about it. Somebody will say, oh no, my ears are ringing. And just like that, they took a volume control and cranked it up. Oh no, it's getting worse. Oh no, I'll never sleep tonight. And guess who's staring at the ceiling? So this will help them understand those emotions and you've got to help them break thinking about it. And then of course, all the thoughts that lead to severe emotional distress have to be taken seriously. And that's where cognitive behavioral therapy comes in very handy as well. Now, thoughts and emotions can range very differently. You take a simple sound like a doorbell. To most all of us, it's neutral. But if the doorbell rings and there's a fire somebody's telling you about, the next time the doorbell rings, somebody fell and broke their ankle and they're in distress. The next time it rings, there's an angry neighbor. But next time the phone bell rings, you may be excited about it. If the phone bell rings and there's flowers, if the phone bell rings and you've won Publishers Clearinghouse, this check is for you. If it rings and your friends are there. Next time the doorbell rings, you think happiness. Now, this is an example of a picture-based slide you can use with people to help them realize that it's the same sound. But boy, is there a variety of reaction to that. So cognitive behavioral therapy basically is this. There's an episode, then there's response and reaction to the episode. So for instance, the example I use all the time is, two women had beautiful marriages, love their husbands and they unexpectedly died on them. One goes through normal grieving. They try to stay involved with the family. They do more things with their church. They might do volunteer work. They wanna stay busy. They have good days, they have bad days. Christmas and birthdays are bad, but slowly they get easier. They go on with their life and maybe even meet somebody new. The other one is deeply affected. They go into, they become more depressed. They don't wanna see the family. They become more reclusive. They stop going to their house of worship. They just can't get through the negative thoughts process and they just wanna die and be with Bill. The exact same thing happened to both of them, but totally different responses. So CBT is used in pain management. CBT is a great tool for grief counseling and CBT works with tinnitus because our thoughts affect how, what we think affects how we feel and act. What we do affects how we think and feel and what we feel affects how we think and act. And having a referral who is good at that is a godsend. Silence is the tinnitus playground. So a person in a noisy shopping center, they don't even notice their tinnitus with all that cacophony, but they sit down to read. They sit down at the computer. They try to get some rest. It's overwhelming. So that's where sound enrichment strategies come in and noisemakers and replacing. You're having a babbling brook, having the sound of a waterfall, having noise machines within the room. Just don't be silent. We have some patients that they have some sort of sound in every room. They sleep with a white noise machine and you take this sound enrichment and through the apps the manufacturer has on their phones and the tools that they have within the device, you can add to the hearing help directly through the hearing aid. We teach the brain to focus on more pleasant sound and so they don't focus on the unpleasant sound. And it's critical that they don't keep score because if they're saying, hmm, like even with the hearing aids, I've got these hearing aids on, is my tinnitus as loud as it was? Hmm, let me think. Well, if you're thinking about your tinnitus, you make it work. It's a weird game, but if you keep score, you will lose the game. So what I mean by if this example is another one that's very easy that Dr. Tyler uses, and he shows you that if there is a totally dark room and if there's a candle in that room, your eyes can't help but look at that. But in a brightly lit room with other things going on, a light above your head, sunshine coming in, a lot of things. I say, if you had walked in and there was a candle burning on that cabinet over there, if it didn't emit a smell or a pleasant aroma, you wouldn't even know it's there, but kill the lights, and it's all you can think about. It's the same thing with sound enrichment. You have to have other things going on to mask out the sound. So I've used this Consumer Guide to Tinnitus Relief, but have literature in your facility to help patients understand their condition. Knowledge is power where health is concerned. All the manufacturers have tinnitus-specific brochures. Find your favorites and put them in your lobby. A medical problem more understood is easier to live with and far, far less intimidating for people. So hearing aids will help many of them, and that's what we're good at. That dials right into our spring. Now, how you do the frequency response will change. How you're adding some of the masking systems will change. That's fine. You'll learn, expand your growth and expand your scope of contribution by dialing into more of these things. Be able to provide brief counseling for people. There are self-help books available. Consider advanced counseling with medical referrals. If you say you need a shrink, they'll say, no, no, it's not in my head, this is real. But if you say we have a tinnitus coach that works with our patients and they use cognitive behavioral therapy, very similar to grief counseling, you tell the story of the two widows. And some of my patients go and see them, they have three to five sessions, instantly they have more tools in their toolbox and they may even tell their kids or other people how to use these tools. It's really how you present the information. Sound therapies are extremely helpful. So your manufacturer may not share all of the wonderful things that their tinnitus apps do, or all their tinnitus functions of their tinnitus treatment. I love that this is sponsored by Widex. I have used the Widex Zen and musical therapy. Music has columns to soothe the savage beast. Well, that works really well, but learning how to use it and learning all of those things, you have to expand your knowledge, offer ear protection products, provide hope for people, be sincere and honest, and show you care. There's that old adage, people wanna know how much you care before they care how much you know. And when you show that caring and you show them things they haven't seen other places and you understand, and you've asked them questions they haven't thought of before, and you've put it in very succinct terms, how A, hearing loss leads to B, ringing ear, and C, this is what we need to do about it. And there is a great need out there. Dr. Richard Tyler is one of the finest people I have ever met. He has, for the last 20 years, had a conference on tinnitus at the University of Iowa. I've attended several of them. They're fabulous people come from all over the world. He teaches AUD, some of the best AUDs. Tinnitus training will come at the University of Iowa, in my opinion. His consumer handbook on tinnitus, get it in your library and excerpt some things, jot some things down, make single pages out of it. There's great information there. And he is an excellent teacher. And if you take this class, you are going to be delighted. Now, I had a chance to work on it. Dr. Sam Hopmeyer, who, I mean, Sam Hopmeyer, who used to be the past president of IHS, who was involved in this. Doug Lewis, who, Dr. Lewis is on your education committee for IHS, is a brilliant man. He was so much fun to work with, and he's done, and he's a great teacher, and he is still part of the class. Bob Mario has done some great things up in his area, up in New England. Dr. Lindsay Prusak is one of Dr. Tyler's students, and she rose on to, she put great classes on audiology online. She trained the audiologist at Starkey about it. She trained the audiology classes. And here in the States, by the way, because of this turf war, they won't overtly go out to HISs because they don't want to be perceived as expanding your scope of practice. But up there, again, that isn't an issue, but you got to ask. If you ask who is the best mind in your tinnitus products who can help me, they will. Calvin Staples is right there. He is a Canadian, and the legendary Dr. Tyler. So tinnitus sufferers need clinicians to offer help and hope. Please consider offering tinnitus care within your practice. It is a commitment in time. Resources, I mean, there is an expense involved. We had nine of our patient, of our clinicians take the very first class here in Orlando, nine of them. And I always used to tell people, if you help an extra two people a year that you wouldn't have been able to help otherwise. You've recouped everything and then some on your resources or your expense involved. It takes energy, it takes education, but in my opinion, this is extremely rewarding. So thank you very much. The class by the way, is coming up November 17th through 19th you can do it online, just like we did here. And I hope this has been beneficial to you, but I sincerely wish you would take the class and learn more so that you can help others. Thank you. John, that was fantastic. Thank you so much for sharing your passion and your expertise with us today, it just shines through the screen. So we'll go ahead and take some questions. As a reminder to our attendees, you can enter your questions into the Q&A box at the bottom of your screen, and we'll take as many questions as we can in the time remaining. So John, our first question is from Christine, and what she said, and she's not wrong, is that it sounds like some tinnitus patients can really take up time in the clinic. And she's wondering how you bill or charge these patients, what does that look like in your clinics? So there's a number of different ways to approach that, and they do, you know, first and foremost, I always used to tell my staff in the beginning, make it my last appointment of the day, you know, so it doesn't back up my lobby, because you don't know in advance what you're really getting into, and it does take more. We found a way, because we used a bundle pricing method, where we had a product, but if we engaged all of the tinnitus treatment, we turned on the Zen, we turned on the masking, we did tinnitus counseling, there was an X amount more for that product line. So we had a tinnitus product page with each of the various manufacturers, and we calculated in what it would take to do it. You know, they always use the time is money analogy, and I get that, and especially in a busy practice, you know, it was, we had to expand our staff slightly, when we started to get involved with tinnitus, so we could take on more and more, but it kind of multiplies what goes on in your practice, you know, you wind up seeing, wow, we may even have to add more people, because we're getting more popular, and there's more people coming in, and, you know, I forget all of the things, you can't be too skinny, too wealthy, too, I don't think you have too many patients in your practice. If you use an unbundled approach, you could have a consultation, Dr. Tyler actually has some things within his curriculum of how they do it at the University of Iowa. He does some group sessions that are obviously cheaper, I've done lunch and learns to bring people out, and they get a lot of the basics before we even see them, so I don't have to do it one by one by one with the patient, it's easier to tell 40 people at once. So there are ways to do it, but the increase in your hearing aid revenue will be phenomenal, and the, but you do have to find out what's best for your practice. Great, thank you, and I would just echo that I've heard from a lot of tinnitus care providers, the same things that John has said, that once you start advertising that and proving your expertise, you know, the referrals will be seemingly limitless, and you'll grow your practice quite a bit. And the step, and the step that takes time of sending the letters out to the primary cares, you know, find somebody who can do that for you and create a template to put it all in, but once you start getting your name on the desk of all the primary cares in your neighborhood, trust me, that will come back to you in spades, it was worth writing the letters. That's a great point, thank you for adding that, John. John, the next question is from Samantha, and it's a very clinical question. So they're asking, is there a window that you found for starting the treatment, so amplification from the initial symptoms for maximum results? So just, you know, do we need to start within 30 days of the tinnitus, within 10 days, have you found any variance in results based on that? Well, so the longevity factor is somewhat important, but the severe, the degree of distress is more important. So on our tinnitus reaction questionnaire, you know, it's always easier to solve a small health problem than it is a big health problem. And the lovely things is, you know, I've noticed I've had a little trouble with my hearing. I've started to have this buzzing in my head. The buzzing seems like it's getting louder. I don't want any problems. I thought I'd come right in and see you. You love patients like that. You know, I mean, somebody wants to see a pre-diabetic before they become a diabetic, you know, somebody, whatever, you want to catch a small tumor instead of a large one. So catching it early helps, but it can't be avoided. So when you see people that are more advanced, when you see people that are further down the pipe, and if it surprises you, if all of a sudden on this 0 to 104, you wind up with a 78, do some basics and set aside a larger window to follow up. You know, I didn't realize I would be getting into this. So let's set up more time and give them enough and give them good literature and give them hope. And I've seen many people like you, and we're going to get you some help. I need to see you Tuesday. And if they come without their spouse, be sure their spouse is there, you know, and do things like that. But early intervention is key. And so I do find, and I say the same with hearing loss, you know, I'm the biggest proponent of early intervention you'll ever meet on whoever starts with the mildest prescription I've always preached that. And so when you're going through a small change, it's going to be easier on them, but you want, and again, you can draw your cutoff line. You know, when someone presents this degree of distress and problems, I've got a great place to refer you to. But if you, if you get even that much better at catching everybody in that 50 and underscore card, and you are great with them, that's phenomenal. But in your counseling to the patient, oh, you wouldn't believe how many people wait until they get to where they can't sleep. They can't think they can't focus. They can't concentrate. And finally, they get the help they need. So use that to your advantage in your counseling, no offense or buts, but you really can't dictate when someone's going to raise their hand and say, Hey, I got a problem here. So, you know, you want to have the tools in your toolbox for as many of these categories as you can. And it just expands over experience. You know, if it's something new to you, grow into it slowly, have other people. You know, I've always told people to reach out to me that actually there's two people in today's. One of them I spoke, spoke back and forth with that's reaching out to me and he's already taken Dr. Tyler's, another one who's considering taking Dr. Tyler's class. And there are resources and I've never found Dr. Tyler's group to turn down an overture for help. So, so help is out there. Help is out there. Thank you so much, John. And when you were speaking, it made me think of, and I don't, I don't know if you have any comments on this, but I wonder if with the awareness, the increased awareness we're seeing in the media and things like that about hearing healthcare, if that might also encourage folks to get help for their tinnitus sooner. And also maybe even in your clinics, if you're advertising that might increase awareness in your local community and eventually see folks who are coming into you sooner because you've increased awareness of the issue. Well, we, we were very blessed. We have a good networking group and we actually do community health fairs together as a team and some of the local hospitals have actually asked me to come in as a speaker. I provide lunch and learns within the community and get people in. And, you know, you want to be more holistic, you know, when we were talking about that scope of influence, do it well, do I want to deal with the fact that they have cognitive problems? Okay. Untreated hearing loss, exacerbated cognitive problems. So you got to know how to talk about it. A lot of people with ringing ear. I mean, there's more people with ringing ear than hearing loss and many more people admit it. So you got to be good at some of that and you've got to know some of these things. And trust me, if you've got cognitive issues, not being able to sleep because your ears are ringing all you become, it's a cumulative effect. So know as much as you can about each and every one of those, you know, when somebody like Dr. Beck, who's like a legend to me, starts listing out, these are all the articles I think you should read, read them all. You know, they're good, read them all. And it's the same kind of thing. If you get that consumer's guide to tinnitus relief and you just take it cover to cover to get yourself started and get yourself going and start pulling out the things you're going to use, you know, it will grow over time. But it took our practice to a whole new level and the feeling of self-satisfaction. I've always told my friends, you never forget the first time someone cries in your test room because they're hearing better. You know, and 40 years later, that never goes away. But the hugs you get when you solve a more severe tinnitus, it's like you saved my life, man. You know, it's I can't tell you how good it feels. And the need is there because there's so many people who need the help and, you know, that go the road less traveled and go the extra mile, put in a little more effort, a little more energy, you know. And I mean, people don't always think like this, but I used to tell people to put that on my last appointment of the day because it happened early and it disrupted my schedule. Then we're apologizing to everybody the rest of the day. But if it happened at the end of the day, I might eat dinner a little bit later, but it was worth it, you know, and it changed things. So that's where I talk about that scope of contribution. This is a way that you can contribute to people's lives and change people in a positive way and do the things the first two authors talked about with testing speech and noise, with learning about cognitive and maybe we've done cognitive you in our office and we've referred people out for cognitive testing ever since the first day after the article came out, you know, and that all tightens into your even feeling about what you do for a living, really changes when you're able to change more people's life in a positive way. And we've all seen people that, you know, that mom's got more lucid once she started wearing her hearing aids and the family thanks you profusely for that. So it's the same kind of thing with the tinnitus when, and as you learn more and you're going to have to spend more time with your reps and you're going to have to learn. And these apps are great because you could use one manufacturer's wireless product and have six different choices of which tinnitus app to use. And everything's different for patients and they could raise the volume of the tinnitus sound, change the pitch of the tinnitus sound on some of them. Some like, you know, soothing guitar music can play into their ears while they're reading and it's just comfortable or crashing waves. There's so much out there, but it starts by taking that first step, you know, and the good news is if you're the first step is to sit down with the brilliant Dr. Richard Tyler, well, the rest of this will come a lot easier for you. It really will. And don't be afraid of it. Whatever you do, don't be afraid of it. And it's when you look at the investment you make in your time, your effort, and your tuition, and you see what that does for your practice. And I know it was the best investment we ever made in our practice was to have someone of that level while he's still teaching this, grab it, because he's out there and he really is that good. Thank you very much, John. The next question here is from Martin, who's asking if you could just revisit the referral criteria or referral points again quickly, even specifically regarding tinnitus. So what happens when it's only in one ear? There are some very benign, not threatening things that could happen that could cause it in one ear. And especially if there's a plausible explanation. Even something like my brother threw a firecracker and it blew up right near it, and that ear rang for about a month and it went away, but now it comes back and it's only in this ear. Well, later you may find as you get better in your testing and better in other things that the problem is actually in both ears, but it's so much more dominant in this ear that it drowns out what's happening in this ear. But there are cholesterol tomas that could be in the middle ear that could put pressure on there. And that can lead to some of that pulsatile, that thumping sound in your head. And that would be a reason for referral. The TMJ, the jaw and the cricking of the neck. And when I move certain ways, you know, saying, well, have you discussed this with your chiropractor or your osteo? Have you discussed this with your dentist? Those are important ones. When you start to see the balance dizziness component, and it could be veneers, especially a veneers patient, when they do their pitch match, it'll be under a thousand. All the time. It'll be like a low roaring freight train instead of a high buzz. So, you know, veneers, there's some things that can manage the veneers, especially the vertigo component, because, you know, that could be scary. Someone could be on, you know, driving in their car and a vertigo attack hits them. So you want to be sure they've gone to the right. And then anything that has said anything but zero in suicide, you really want to work with them and follow up. And actually, I take the step of, if I give you a business card, you may or may not call. If I set you up with an initial consultation with one of our tinnitus coaches who will discuss some of this cognitive behavioral therapy that pain sufferers have gone through for pain management and grief counselors have gone, they'll give you really good tools in your toolbox. Is there a day of the week that doesn't work well for you and really take it to the next step and book them out, you know, get somebody who, you know, some, there were a couple manufacturers. I think that's quelled some. Neuromonics used to do it where they would teach psychiatrists and teach psychologists about the tinnitus patient. But you want to have a sit down with them as you get your knowledge and then just say, this is what we need. And if you say CBT, they got it from here, you know, and then that dovetails into your tinnitus activities, therapies that you're presenting within your practice through Dr. Tyler's training. That is all very helpful. And, you know, they fit hand in glove. So those are the, those are the big ones that you want to refer though. That's great. Thank you so much for going over that again, John. The, this is a follow-up question from Samantha who asked about the length of time from onset to amplification. If you had thoughts on that, which you responded to greatly, she said, or they said that they have a colleague who believed applying amplification within the first year of symptoms increases the chances of eliminating the tinnitus. Have you seen results that would specifically suggest that? Early intervention is helpful. So if you take someone who's like a six on a TRQ and just starting to do it, and you're not introducing much amplification because their hearing losses is calmer and their tinnitus symptoms are calmer, you're on the right track. I mean, you, you, I wouldn't go out and state empirically that if you do it in the first year, it'll be behind you. But if you let this go beyond 12 months, it'll be a problem. Cause I've had people with 20 year problems that it took them a little longer to get there, but they eventually, I remember vividly. And by the way, that scorecard where you grade from the zero to 104, don't do it often because if people think about their tinnitus, they make it worse. So don't make people think about their tinnitus. You know, when you come in, you ask how they're doing with the hearing aids, ask how they're doing with their apps, ask how they're doing with things, but don't ask them to grade their tinnitus because we saw case after case. Dr. Tyler said I should do it every 18 months, but we were doing it every year. We would redo that little questionnaire. And, you know, we, just like the onset of hearing loss, we don't notice it because it happened so gradually. Okay. The relief from tinnitus, we don't know because that's happening gradually either. And someone who scored an 86, 86 out of 104 on their initial visit, we did a one year redo of the test and they were down to a 22 and they sat there though. And they said, you know, I'm sorry. I'm sorry. I even got into this mess because it hasn't gotten any better at all. And then I brought them out page by page. When I met you, this bothered you almost all of the time. Now you've scored it and never. This one bothered you. You don't say in advance why you're doing it, but they may not realize they're doing it. And to me, someone going from an 86 to a 22 is such a huge difference in their life. My sleep bothered me almost all of the time. Now it's occasionally, you know, you, so you have to reinforce that with them. And that's a little sidebar to answer to your question. But yes, taking a 20 down to a zero is vastly easier. You know, there's less baggage and it hasn't had as much time to really take hold. So yes, if you are starting to notice symptoms, get used to it. And the mild amplification of the hearing aids, you know, when you've got strong hearing aids and then the fire alarm goes off. Yes, the compression will kick in and protect them and all that. But when they go to the noisy restaurants, all these other things, stronger amplification of hearing aids, if they're the type that have reactive tinnitus, that exposure to loud noise makes it worse for a period of time, then certainly you want to start with mild prescription. And, you know, so you're not going to be amplifying the sound. So yes, I am a 100% state to the patient that small health problems are easier to take care of than big health problems. I just wouldn't go out on a limb and quote that we've only got till here and then it gets harder or it may not be able to be done. Because I've had people that have had really longstanding problems that we've been able to change their lives tremendously. Just right. And we don't want to discourage those people who've been experiencing tinnitus longer from coming in and seeking help, right? Because we know they need hope. You know, there was one clinician, she was a really good audiologist who had done it for 30 years. So I'm not saying to do this. But in her mind, when people would tell them about the problem, she would say, this will be a piece of cake. And none of us would consider tinnitus a piece of cake, especially severe tinnitus. But she said, if I can just have that confidence and get that kind of buy-in from them, our chances go up astronomically. And so I am just going to be, we're going to now tell people in advance, realistic expectations. I'll say, well, notice the progress in your hearing in days, weeks tops. We measure progress in your tinnitus in 9, 12, 15 month intervals. You know, it's not an immediacy. Now, if you tell people in advance, that's an explanation. If you tell them later, it's an excuse. So why hasn't this worked yet? Oh, this usually takes 12 months. Why didn't you tell me that up front? So be sure that you're, I've always believed in under-promising and over-delivering. You know, it's been my mantra for every clinician. It's like, don't oversell, and certainly not in the tinnitus. But if you tell them of cases you've had, constantly, as you start to get more and more in your toolbox, and you've got more and more success stories. And they're the patients, by the way, that will write nicer testimonials, because it's more life-changing. You know, they may not see that, you know, they don't want their friends to even know they're wearing hearing aids. That's why I got those discreet lines. I said, no, no, I don't want to be a testimonial for hearing aids. I don't want my friends to know. But when you've taken them from, man, I couldn't sleep. I couldn't think it was affecting my moods. It was affecting my personality. I am so glad I met you. I will gladly tell the world the kind of stuff you've made. And they start seeing that on your website, and they start seeing that. And, you know, then you could just say, well, here's what some other people have said. And turn your screen around and start clicking on your site, and bring out some of the patients. And if you know them personally, you know, you can relate some things. So you got to watch the HIPAA and health, you know, the privacy things. But if they volunteered to do that, usually they'll just be their first name and last initial. So, but that's the kind of thing, you know, start quoting stories about it. But in general, everywhere in life, a small health problem is so much easier than a big health problem. So, yeah, nip it in the bud. Don't wait till this gets nasty. Don't make my job harder. Let's just fix this. Let's just fix this and move on. Because there are too many that think, how long can I do without before I cause myself permanent harm? And later on, it's one of those, dang, I wish I did this sooner. Why did it take me so long to come to see you? Is more the reality of it. So yes, yes, nip it in the bud as early as you can. Excellent. Thank you so much, John. That is all the time that we have for questions. Again, thank you so much, John, for sharing this information with us. Your enthusiasm exudes and it's much appreciated. Always a pleasure working with you. Before we proceed with our final speaker of the day, we are going to take a quick break to get up and stretch our legs. So we'll restart here at 3.30 p.m. Eastern time. And don't hesitate to reach out. I really mean it. If you write to me, I will answer you and go see Dr. Tyler. He's great. Bye-bye. Enjoy the rest of your day. And another value add, clean some ears in your practice. Is that a good foreshadowing? Thank you very much, John. All right, folks. We'll see you back here at 3.30 Eastern.

John Hoagland

tinnitus care

hearing healthcare professionals

tinnitus and hearing center

cognitive behavioral therapy

sound enrichment strategies

referral criteria for tinnitus patients

emotional aspects of tinnitus

hearing aids

helping individuals with tinnitus