EPISODE 40 [INTRODUCTION] [00:00:00] ANNOUNCER: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Start today. SpeechTherapyPD.com has over 175 hours of audio courses on- demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On The Ear, you can receive $20 off in annual subscription when you use code Ear21. Just head to SpeechTherapyPD.com to sign up and use code Ear21, E-A-R-2-1 for $20 off your annual subscription. [00:00:48] DS: You're listening to On The Ear, an audiology podcast sponsored by SpeechTherapyPD.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor, and lifelong learner. While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance, and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues, and students. Let's go. We are live and On the Ear, brought to you by SpeechTherapyPD.com. [OVERVIEW] [00:01:36] DS: Even as the global understanding of hearing loss and its widespread impact continues to expand, patients continue to face barriers to their access to hearing healthcare. While policy and practice changes have helped to deconstruct some of these barriers, the COVID-19 pandemic only highlighted where so much work still needs to be done. Fortunately, healthcare professionals across disciplines are working to better reach underserved populations through innovations in telemedicine and outreach. Today's guest is here to share how his work is helping to close that gap. Dr. Matthew L. Bush, MD, PhD, MBA easily the most credentials and degrees of any guest ever on the podcast, is the Vice Chair for Research and a professor in the Department of Otolaryngology-Head and Neck Surgery at the University of Kentucky in Lexington, Kentucky. He holds the University of Kentucky College of Medicine endowed chair in Rural Health Policy. He earned his medical degree from Marshall University, School of Medicine in Huntington, West Virginia. He completed his otolaryngology residency at the University of Kentucky. He then completed a postdoctoral research fellowship and his otology and neurotology and cranial base surgery fellowship at The Ohio State University. He also completed a PhD in Clinical and Translational Science in 2017, and an MBA in 2020, both of them from the University of Kentucky. His research is focused on hearing healthcare disparities. He serves as the PI of several NIH- funded community-based trials to promote hearing healthcare access and utilization among underserved populations. [DISCLOSURE] [00:02:57] DS: Just a couple of financial disclosures. I'm the host of On The Ear and receive compensation from SpeechTherapyPD.com. Dr. Bush receives compensation from SpeechTherapyPD.com for his contributions to today's presentation. [INTERVIEW] [00:03:07] DS: All right, Dr. Matthew Bush, it's so awesome to have you. Your reputation precedes you in the best way possible and I'm so excited for you to be joining me. How are you doing? [00:03:17] MB: I'm fantastic, Dakota. I am elated to join you and very thankful to talk to these topics, these issues. But to make a new friend and further work together towards addressing some of these challenges. Exciting and thank you for those kind words. All those degrees don't mean a whole lot in a pragmatic sense. I feel like there's an inverse relationship with the number of degrees that you hold, and how much you actually really know, practically. I feel like with any more learning, something else useful falls out of the back of my head. [00:03:57] DS: Because there's a limited capacity. But I don't know, because the work you're doing too, is also Ð I mean, there's a lot of ways that you could approach disparities, and I think your degrees kind of speak to how convoluted this issue is, right? If you have your MBA business standpoint of thereÕs the financial impact in the financial limitations of disparities, you've got your MD, so you've got the more medicinal, physical impacts of this, and then your PhD, and more the research, and the more widespread population impact. I think, you have the perfect setup. I think, there's probably plenty of room in that brain of yours to tackle some of these issues. I think, your research alone, your reference list is out of control. I'm so interested in what drew you to this topic specifically. I mean, was it in your MD? Was it when you were going for your PhD that you started to hone in on this topic of healthcare disparities? What led you to this point? [00:04:51] MB: Yes. Well, there's no doubt that my academic degree pedigree is demonstrative of an immersive approach to try to address disparities because they're complex. They thrive in the pragmatic and the complexities of life from, like you said, the business, the medical, the research side of things, and we have to have different approaches. But for me, it's really been a very organic and natural thing for me to pursue research in this field. I'm an Appalachian, by birth, by God and grew up in West Virginia, was very well provided for and grew up with means, with parents that were hard working and had access to good educational resources and good health care. WeÕre observant of basic things that their family needed for public health and wellness. The reality is, is that growing up in an environment, where rural life and rural communities gives you a sense of those that have and those that have not, and there's many other people who have grown up in an urban city and urban environments that may have had some similar connections and learning. They have had opportunities to excel academically and professionally. But still, their family, their friends face inequities and challenges in health care. I think, growing up in West Virginia really gave me a grounding, if you will, in understanding the simplicity of rural life, the beauty of rural life, and sometimes the needs that are there, but yet also some of the fatalism that can occur in cultures of just dealing with disparities by saying we just accepted life is hard and there's not much we can do about it. In medical school, those things were really impressed upon me. The most influential physician in my medical school career was a family practice doctor who made old school house calls out in the rural hills of West Virginia, would bring flu shots to invalid, housebound, older adults, and, really found himself, that I need to be out there and in the community. That really impressed something on me. Because I saw the joy that was in the providerÕs face and in his life and in his words. You can see it also in the patients that welcome that doctor like a family member to the front porch. Then, took a really sharp turn to residency as pursued to learn laryngology residency. I really felt the need to address and see the challenges as it relates to hearing health care. Being a resident here at the University of Kentucky, which is in Lexington, Kentucky, right at the precipice of Appalachia, but still nestled in central Kentucky that's surrounded by very rural communities. Seen huge differences, let's say, in pediatric hearing health care. Those children that were born in and around the Lexington area, having ample access to care, and timely delivery of diagnostic and treatment options for hearing loss. Those coming from the more rural eastern Kentucky areas, not having the same opportunities and the same timing. Then, that's just continued. As I've pursued, I realized, I want to pursue a career in academic research. I've done bench research and had some really great opportunities along the way in fellowship and early career for some more bench work. But my heart just kept driving back to what I've learned in my family reunions, in my medical training, but then also, in my own practice, of just getting back to where the greatest needs are in the community. [00:09:00] DS: Wow. Yes. It sounds like it's really informed by a lot of different aspects of your life. But I think having that personal connection is probably Ð the fact that you can't really escape it, right? You check in with family, and it's okay, there's still work to be done here in these rural communities. I'm curious, how much of Ð and we're going to dive into different disparities and different facets of that. But I'm curious how much in your work you've seen location, geographic location play into that? Do you feel Ð I can imagine that historically, over the course of medicine in our country, that geographic location has always been a limiting factor, and a cause of disparities for health care, right? I mean, if you can't get to where the care is, that certainly limits your ability to receive it. I'm curious where you've seen that just from growing up to now, how different it is maybe in the town you grew up in or with family members that were even more rural. I also grew up in a really rural town in Virginia. I remember, I mean it was an hour and a half drive just to see the pediatrician that I saw. It was always a really big limitation to getting care there. But I know now, going home and visiting, there's a lot more populated Ð cities grow and spread. It's a lot easier to get to these things. I'm just curious about what you've seen, maybe on that personal level in terms of access to care for these rural populations through your time in your career? [00:10:24] MB: Yes, thatÕs absolutely the truth as far as this very slow diffusion of care, even specialty care into rural areas, and sometimes, I'm shocked that I'll be in some remote rural location. I provide care in some pretty remote clinics that are a couple hour drive from here at the University of Kentucky. I'll see a patient in a restaurant or in this clinic, who come in, who got a cochlear implant. There may be no one else in the county that has a cochlear implant, but yet, here's a patient who was abled somehow, some way, to have hearing health care, not only with hearing aids, but has appropriate move towards cochlear implant or receiving implant, and yet find ways to get an implant programmed. So, it has been interesting. But the geography is an issue. These are things that we do find in our research, that distance makes a difference in timing and delivery of care, and it influences the access and utilization of care. But there's a lot to the different places that are related to the culture and the community. That issue where you have the only Ð you're the only patient in the county, or in several surrounding counties that have a specific type of device, or a specific type of condition. It can be pretty isolating and that's a unique thing. Those people can be bright rays of sunlight to others that may have the condition because they can provide some personal knowledge of what they experienced and what their journey was. But I think it's really interesting. To me, I use that phrase. That's what I've seen. It's just like, this very delayed release, and slow diffusion of technology and resources that will get to remote places, just the same way that iPhones could find their way anywhere on the planet, and even in the most remote area. It's just not going to be an iPhone next 2.0 or whatever, the most recent version of it. But nevertheless, the technology and these things can continue to be diffused. [00:12:56] DS: Yes, they find a way into these places. [00:12:57] MB: It's amazing stories, how these people can find a way through a connection, just an opportunity that they just seize. [00:13:05] DS: I'm sure one of the ways that you're able to provide care into some of these places is via telemedicine and I know that's been one of the leading ways we've seen access improve over the last couple of years. But I had to give you a shout-out, because just brushing up on you and then also on a different project I'm working on personally. You had a paper on telemedicine for hearing healthcare. In 2019, it was published, so I'm sure you were working on that prior to 2019, way ahead of the curve, pre-COVID, with the telemedicine paper. I'm curious what got you on the track into looking into telemedicine for hearing care, and how you've seen that change since that paper? [00:13:46] MB: Well, I guess in some ways, it's good to be ahead of the curve. My kid will be the first to tell you that dad is not a trendsetter. He's not going to set a trend that everybody else is going to follow. But honestly, telemedicine has been a love-hate relationship in my brain, in my research, and in my career. Because a bit Ð because of what we do in hearing healthcare, either as an audiologist or an otolaryngologist, there's a lot of examination, understanding nuances. There's diagnostic testing that's very operator dependent. Of course, surgical procedures. Those are hands-on things. So, there's limitations of what we can really do. To tell you a funny story, when I was finishing my fellowship, I trained at Ohio State and was fortunate to train with some really great clinicians and scientist. My primary mentor, Brad Welling, has been a guru and in F2 and schwannoma research, and really has made a wonderful career of work in bench lab and translational work related to that. As I was considering a career in that too, I also had this passion and drive for health disparity research. Brad really encouraged me like, ÒThis is this could be a career. You could really pursue this.Ó There was a grant that came up about for me to apply, it was a collaborative grant between where I was training at Ohio State and UK, where I was coming back to join as faculty. I applied for this grant. I wrote it passionately and had this huge telemedicine component that was a part of it. The grant didn't get funded. I'm like, ÒHow can this be? I'm the golden child. I'm coming back from the promised land, into the motherland, and I've got all these great ideas. How could this not get funded?Ó Well, it wasn't that great of a grant. I mean, that's why it didn't get funded. But I went to go find the person. I wanted to learn who actually got this grant. It's this brilliant behavioral scientist, medical anthropologist, Nancy Schoenberg, who was ended up being a tremendous mentor. Became my primary mentor for my career development award with the NIH. So, it was like my enemy became my friend and one of my greatest allies, because of telemedicine and my inability to articulate what to do scientifically. That was the challenge. I came in thinking, all right, what I'm going to do is I know there's a problem because I'm a clinician, and I know that my observations have to be scientifically valid. How could they not be? I'm just going to fix the problem right away and throw a tele-whatever, a tele-widget at tele-ABR. I'm going to put something in the community, and patients are going to flock to it, and we're going to do all these diagnostic ABRs remotely. The whole idea just became like, this is this giant wall of poor timing, and wrong questions, and wrong approaches to try to address the problem. You need to understand the people, you need to understand the culture, some of the nuances before you immediately start to fix it with telemedicine. It's interesting that the pandemic has really pushed fast forward on everything that's telehealth related, and it's opening up amazing opportunities for the next century of healthcare for us to deliver different aspects of things remotely. But it's still complicated. It's still limited by so many different things, and my life lessons in my research have been like, don't just rush into telemedicine. Figure out how, when, and where, what's going to really contribute to sustainable work, that can really benefit health. [00:17:55] DS: That's a really great approach to it. I really appreciate your humility and sharing that story, too. That's awesome to hear. I know that the process of being a researcher can be Ð there's a lot of evolution that happens over the course of the career. I think that's a really helpful insight for people who are maybe on that track. I know, I have a good friend who's been on the podcast a couple of times now who's out of Georgia. She's an audiologist there. We've had two episodes now, where the first one we recorded in 2020, where they had the funding obtained. They started a mobile audiology unit to get to these really remote parts of Georgia, to provide care. They were having a huge loss to follow-up rate on newborns, which was historically a problem in many states, and then with the pandemic has only been exacerbated. She was really excited about this project. But the pandemic had just started, so they were trying to reorient and figure out what they were going to do. Then, we checked in about a year and a half later, and they had basically converted this original idea of going out into the communities into a remote tele-ABR system, and just listening to her process of working out the kinks. I mean, you really would think with how accessible the internet is, for most people, it still isn't in a lot of these rural communities. I mean, it would be crazy to me to go into a metropolitan city and not be able to have Wi-Fi in just about every single building I entered. But the amount of hoops you had to jump through to find a health department that had Internet, that was open to guests, that they could bring in babies and train these minutes. Still in 2020, I think that was a 2022 episode just so challenging. Just from the logistics side, let alone finding families and counseling them, and the manpower of it, but also, just the logistics of the Internet are still really hard to make accessible. [00:19:44] MB: That's the truth. That's the truth. I mean, so many different levels. I guess, if they had a degree in telemedicine or telehealth, I guess that would be the next degree I would need to pursue. [00:19:55] DS: Let's not get any ideas here. [00:19:58] MB: Yes, for the cycle. I'm good. My family gave me an ultimatum, like, no more, you're done. Call it quits. But the reality is, that's the truth is that we take so many Ð we make so many judgment calls and presuppositions of what we think people know, and what we think they feel, and what we think theyÕre really facing. There's certainly logistics and the real material equipment, the technical challenges. But there's cultural challenges too. We have to ask ourselves, does the community really believe that, A, this testing is accurate? That, B, it's going to lead anything meaningful in the future, the quality of care, or important outcomes that matter to them for their child or their loved one? That's really important. I think I've learned that, more than anything else, is that people Ð if people don't believe, the community doesn't believe in this intervention, this treatment option, this new opportunity, then it's going to fall flat. People in the community really have to believe in this. Even more than just believing in it, they need to feel like they're part of the solution, and they're partners in innovation, and partners in solutions in trying to address care. It's not and it can't just be about handouts. It has to be co-creation, co-innovation, and I've learned a lot of that the hard way. But thankfully, with some really bright community partners that give some very, very helpful feedback on directions that we follow. [00:21:46] DS: That's really interesting. I don't really know that I've heard that perspective before, and I think that makes a lot of sense when you think of initiatives that have Ð they get the funding, they get all of their ducks in a row, but they didn't start with community buy-in and ultimately, end up failing. I'm curious what that looked like? I'm not sure if you've been a part of an initiative that took that approach. What does that look like? Is it being a part of, I don't know, town hall meetings? I don't know. I'm trying to brainstorm here. But what does that ultimately look like in getting buy-in from the culture, from a location like that? [00:22:20] MB: The core axiom that we live by in pragmatic research, that it's involving health disparities, and health equity is about community advisory boards. Community advisory boards can look a lot of different ways. It can be composed of lots of different types of members. But it's really about giving a voice to people who are stakeholders and can play a role in either the success or the failure of your research, or your initiative, or your scientific questions, or even program development or clinic outreach, for example. But gaining the perspectives of those different community members. It could be an educator. It could be a school superintendent, school superintendent or school board member. It could be a politician, a council member. It could be a parent. It could be a caregiver for an elderly adult. I mean, it really depends on the question in the community. But I think whenever we barrel head first into a community that has historically been marginalized and dismissed and say, ÒHey, here's the latest and greatest. Here's the solution.Ó We've come from the big city with this shiny, new, whatever. There's a lot of skepticism. We've learned a lot through some of the tragedies and travesties of racial bias and racism lived out before our very eyes, on news broadcasts, and through different scenarios in our society. You look at racial and ethnic groups that have been persistently overlooked, and given these types of Ònew, fancyÓ resources and opportunities, to not be backed, and not be supported, and not to get any community input, they fall flat. The same is true in different groups geographically and perhaps rural communities, regardless of their racial or ethnic makeup, as that people have been sold a bill of goods year after year, decade after decade, promises that were made that were not kept. It sometimes can create a little bit of skepticism in the community. If you get a Ð my advice when I talked about disparity research and pragmatic work is that everybody that's involved in this field needs to have a community advisory board. No matter what kind of research or clinical care you're trying to involve in, if you're not having a formal way to perhaps informally, but yet consistently get the input of community members and stakeholders, then I think we really do ourselves a disservice, and we're just not going to be grounded in efforts that we make. [00:25:24] DS: Wow, that's so interesting. I definitely see the connection between those two concepts. I'm not personally involved in this initiative, but where I work, we're putting together a mobile unit to help reach. It started, specifically, for our pediatric cochlear implant patients who are driving four or five hours across the state, setting up this bus so that they only drive an hour or so or less, and we see several patients in a day. But now, the role of this bus continues to expand as we see the need across the state. I'm assuming that the people involved in the planning of this our investing in these conversations with community members. But yes, I can definitely see how Ð thatÕs how you get the buy-in, is you have leaders of the community who are bought in and you're not going to convince these people. You're not these people. You're not in this community. But the people who are definitely will. That's a really interesting perspective on that. I'm curious what other Ð we've talked about rural, or not just rural, but I guess, geographic location as a potential cause of healthcare disparities, maybe racial and ethnic differences as well. I guess, we haven't really dive too much into the history of that. But I know that that's historically, like, in one of your papers, you guys talked about that a bit too. What other aspects of care should we be considering when we're trying to address our own biases, or really look at disparities in hearing healthcare? [00:26:43] MB: Unfortunately, it's an ocean of whenever you start to ask questions and start to look, then you sometimes get answers that you really don't want to get. Sometimes when I started to talk about disparities, or give a talk on the matter, I feel like, I am just nothing but doom and gloom. I am just telling everybody in this auditorium, or in this audience, how bad everything is, and it's not that bad, and that there are options, and there's hope, and there's opportunities. Collaborative work is moving and grooving and working to make differences. But I think it's important to understand that disparities are deeply rooted in lots of different dimensions, and we can consider the factors that are influencing and allowing the propagation of disparities year after year, decade after decade, that come from these different domains of the social determinants of health. As a clinically trained otolaryngologist, a surgical subspecialist, I never really thought that social determinants of health would ever be a part of my daily dialogue or discussion. But if you care for patients, and if you care about where they come from, and where they're going, and what today is like for them, you have to be thinking about, this is more than just a clinical encounter that they are facing either barriers or facilitators that are rooted in these different domains of the health care access, and the quality of health care, and s the health domain. Then, you've got educational access and quality, their background of what their education has been, their health literacy. You've got social-cultural influences, and imprinting that influence their behaviors, and where they go, and who they see, and who they're willing to listen to, and who they trust. You'll have neighborhood and built environment factors that influence that geographic place of where they live and health factors that might influence them, their socio- economic position, whether there are financial resources and opportunities that are before them. All these different social factors that are very different than the genetic causes and the biological causes. But they imprint every single patient that we see in every clinical encounter, or that are a part of any research study, and it affects people from cradle to grave. Throughout the entire lifespan, these influencing factors may either protect from disparities, or may propagate and make the disparity somewhat resilient and obstinate to change. I think that's an important thing to frame things in terms of these different influencers. But when I think about the continuum of hearing health care, that it starts way before they are in the operating room for a cochlear implant, or they're in our office for a diagnostic audiogram, or the healthcare encounter with a specialist, perhaps, is involved. But their journey begins a long time before then. There is this knowledge, this self-awareness that occurs. There's interface between primary care providers where maybe hearing health care is discussed, maybe it's not. If it's an infant, whether they have access to high quality or meaningful EHDI services and consistent follow up through the EHDI system. That entry into hearing health care is really important. For me, as a researcher, that's where I really think about. I've had to ask myself, ÒHow do I try to study the patients that never come into my clinic or never come to our audiologist?Ó We're not responsible for them, because they never got here. But I would argue against that. We, as healthcare professionals, hearing healthcare professionals, need to think about all the people in the outside, and how do we find a way to extend our circle or our sphere of influence, to bring them inside hearing healthcare and awareness and on the path. To me, that's a really interesting and important aspect of research that can help us ask some important questions, and then maybe get some meaningful answers that could lead to more efficient or effective entry into hearing healthcare. The other important issue is where there are transitions, where you're moving from one clinical encounter to another clinical encounter. From diagnostics, to therapeutic. Or from one type of therapeutic, such as hearing aids into another therapeutic such as cochlear implants. Those transitions are places where you might consider an analogy of leaky pipes, where you're going to have patients that are lost to the system, and they don't want to pursue anything else. They're eligible, but not interested. Those are really important issues. That ties into that whole continuum of hearing healthcare, that disparities are just Ð there's so many opportunities to study and address it from a research standpoint. [00:32:04] DS: Yes. I definitely like using this idea of hearing healthcare as a continuum to see where the gaps can occur, and having that as the basis. I see what you mean. There's this balance between the doom and gloom and the hope of it all. We've had healthcare in our country for a long time, but it seems like a lot of the issues are probably pretty similar to what they've been. Where do you approach this? I think it's helpful, because not everyone listening is probably a healthcare disparity researcher like yourself. But they do either want to, maybe, at least ponder the impacts on their clinical care or start to consider solutions for their clinics. Things they can implement to help with that. When you think about how broad the influences are on this, where would you encourage someone who's starting out? Okay, there's clearly healthcare disparities where I'm working. I want to do something about it. I'll just throw, like a real-world example. So, where I am, working with pediatric cochlear implants, the no-show rate is just terrible. I see it more for the kids who come from rural areas. I see it more for low socio-economic status families. How do I help the people that I don't see? I can't talk to them and ask them, what are the barriers here? How do you approach those kinds of situations where it's not easy to get in touch with them, but you want to help address that problem? [00:33:21] MB: The first thing and the most important thing is, don't throw up your hands and say, ÒI can't fix this.Ó Or, ÒI don't really know what the problem is, and I don't know what to do, and just to give up from the beginning, you have to just have an openness to acknowledge that, ÒOkay, as a clinician, I perceive there's a problem. But let's try to figure this out.Ó The first thing and you don't have to be a researcher to try to define or describe it. That's the first and the most important thing, and that's certainly where I started in my research is to say, ÒI need to be able to articulate that there is a problem.Ó I can't just go on my clinical intuition alone, or just interesting heart strings, pulling stories of a child or a patient who was delayed and didn't get their care. But I need to find out somehow, some way to use data, the power of data to tell a story. It doesn't necessarily have to be published research literature. I mean, we can go through our EMRs with much more efficiency these days, than we could with our old chart system and have to look for no-shows or not, or some of these old scheduling systems. I think we're a little bit more efficient as far as EMRs. But if we can define and describe, okay, there is a population, maybe a racial group, an ethnic group, a cultural identity group, or individuals from a certain geographic region of our city, or of our state, that are not getting the resources, begin to use some data to define it. Why that's important is because data can change opportunities. Data can open people's eyes to, there's an issue here. When we're talking about health systems, people see those no-shows as, unfortunately, as dollar signs. Sometimes administrators may not care as much about the outcomes that we care about, language development, or social isolation, cognitive load, or cognitive decline. Those things are maybe meaningless to certain administrators. But if you can connect it to lost opportunities, or loss of financial resources, then sometimes it can then open some doors for discussion of what are we doing programmatically to be able to connect. Because we learned this in academic institutions, is that not all people learn the same way, the way that we communicate with our learners, certainly with our patients. There's different means of communication that's more effective than others, and we might need to be able to reach out in different ways to schedule appointments, or to maintain follow-up visits, or to have patients pursue that recommended treatment, through some different resources and support than we might think in our brain. Again, it starts with acknowledging that I think there's a problem, let's get objective about it and find some true data that will describe or define the problem, and then let's use that to try to identify and partner with perhaps our local team, as well as maybe members in the community, again, that get that community advisory board comes up to the forefront again. Then, devise and develop maybe some pilot or test programs that could be able to move the needle in the right direction. You don't have to fix it all. But to do nothing, is really Ð is giving into the problem. Do something is essential. [00:37:06] DS: That was just so practically helpful. I really appreciate you breaking that down. I think anyone out there who is struggling and feeling the weight of the patients, you're not reaching. I mean, I really think that's just a really practical way to approach that and I really appreciate you sharing that so clearly. Tell me a little bit about your current caseload. I know you are a practicing physician. You're probably in the operating room and providing clinical care, and then, you've also got your research going on. Then, in the back of your mind, the patients who aren't showing up and what you can be doing to help with those disparities. I'm curious what your approach to clinical care looks like with the background of all of these things that you bring into clinic with you? [00:37:44] MB: I'm so fortunate. I feel like I've got my dream job to be able to see patients with about half of my time, and the other half of my time be devoted to funded research programs. It's a dream come true. They really do synergistically work together and energize each other. A day in the clinic, a full day in the clinic, even like today, I was in the clinic seeing patients all day. It's a tiring day, but it's also energizing in a way to know of the human interaction and connections that are made, the opportunities to speak some truth, or some opportunities and some clarity into the lives of people who've trusted me with their time and their ears. That's meaningful. Jumpstart some research ideas and what we do through some of our research conversations jumpstart, then an excitement to get back in the clinic. It's a good thing. I've got an attention span problem to be jumping from one sphere to the other side, other spheres. But to me, they're not all that divergent. They're really very similar and they're meant to connect. That is a key in my life for not only joy and happiness in my work, but also sustainability of just not being burned out. Finding value, finding purpose. But I will tell you that, the more that I've been involved in this disparity work, not only quantitative research to define and describe problems, but qualitative research where we actually ask open-ended questions, and then we shut our mouth, and then listen and let patients really describe these barriers or challenges, whatever that research project is trying to address. I find that it really builds my sympathy, my empathy, my humanity toward my patients. I feel not inconvenienced. I don't feel like, ÒOkay, hurry it up. You're taking too long to describe your dizzinessÓ, but trying to just be a very empathetic active listener. That's really important in this physician-patient trusting relationship. I feel like, disparity research has given me a bigger heart and deeper passion for my patients to be an advocate for them, regardless of their means or their opportunities, and then just to really, listen well to them. That's been important. As I've gone throughout my career, I want to get better at what I do. I want to be a better listener. I want to be a better surgeon. I mean, we always want to continue to improve and hone our skills. But disparity work for me has been a jolt of humanity that keeps me grounded with them. [00:40:37] DS: I can see how that would be the case, right? You get to hear these true stories of the limitation. Like you were saying earlier, a lot of the time, we can't know as much about the disparities, because those are the patients we're not reaching. But with your research, those are the people you're learning from, and you get to take that right into the room. That family that drove for hours and had a broken car and all that, I mean, that just means so much more when you come into it with the perspective of seeing the bigger picture, right? [00:41:02] MB: It's so easy to get cynical, right? We're so quick to say like, ÒWe had this three- hour cochlear implant surgery scheduled today for 7.30am, and you didn't call us until this morning. What's wrong with you? Now, I got to wait around for three more hours and hope that the next patient shows up.Ó Or, ÒWe had this sleep-deprived ABR, and this baby slept the whole way in the car and won't get this ABR. We got to cancel it. I mean, this lost opportunity. We've got a lost dollar symbol.Ó How quickly we get so cynical. But realizing that there are so many things. I mean, perhaps that family didn't make it because they thought they would might be able to make enough money to pay for the gas, to get one way to Lexington to that appointment, and then maybe get back home. But maybe they just didn't make ends meet. I mean, they might have had to choose between food for their family, versus a trip for a clinical encounter. How dare we think that this is a person whose Ð their sole existence is just to be an irritant to me. It's just a really shameful way that is very identifiable. We can all identify and know that we've had feelings like that. But pull yourself back and think in terms of like, ÒAll right, am I thinking like a human being? Or am I just thinking like an irritated, semi-burned-out clinician?Ó I don't want to live the rest of my life and my career being that burned-out person. [00:42:31] DS: Yes. That's a great reminder. I really appreciate how you can pull this back down to Earth with that thing. I know, I found myself in that situation before, that mentality, and you're so right. When you do get to see them and you do get to hear the story and how much more that can help ground things, keep you from being cynical. Are you providing any telemedicine these days? If so, I'm curious, that first grant, right up to today, how you've seen that care shift over the years? [00:42:59] MB: We do deliver some telehealth. We've had a pretty proactive telehealth program to reach some very rural clinics and Appalachia, here through UK Health Care, our healthcare and organization here as a part of the University of Kentucky. That's been a long-standing program that's been very active across multiple types of disciplines. Behavioral health and psychology and psychiatry, neurology, a number of services are very, very, very well for a decade and a half, two decades. ENT, our department has been involved in some ways through some satellite clinics and have continued to provide. It's much more accessible. You don't need to go to a telehealth center, where there is a setup for this. But, I mean, any clinician, with a camera on their screen can do their telehealth encounter through Epic or whatever EMR system. There is continued telehealth delivery. There's aspects of care and limitations of what we can do telehealth-wise. Those diagnostic appointments, especially for pediatrics, like ABRs, remote ABRs. These are things we've done some work in the area. Technology can be expensive. It's even more expensive to have good help and consistent health on the other end of the fiber optics or of the Internet connection. That's often where the challenge is, is finding the right partner in the community. We've seen a number of flares, some bright bursts that faded as you lost a medical assistant or a community member on the other end, that we just couldn't keep a program sustainable. But that continues. For us, like I said, as I initially thought telehealth is the program, I think is more of Ð I think more of my research and intervention has been about how do you build trust in the community? And how do you get the community involved in trying to guide and direct entry into care, or support the transitions of care, and utilize resources that are already existing. That's where we focus more of our efforts is less on the technology and more on the relationships and harnessing the power of local community, stakeholders who are advocates for hearing healthcare. That's really where we've landed with a lot of the interventional work we've been exploring over the last decade. [00:45:49] DS: That's great. I think the grassroots approach to that is probably super effective, and a lot easier to maintain, than just a one-time pop up shop approach. What do you feel like big-picture policy changes could look like to help improve these disparities? I mean, I know healthcare disparities have been around as long as there's been healthcare. But with your background, both research and growing up in a more rural area, where do you see Ð I don't know. This is a vague question. But big picture, policy changes, either at a state or a national level that could, you feel, this is like, what do they call it, big sky idea making, right? What's something we could implement that you feel like it really reach a lot of people and make hearing healthcare more accessible? [00:46:38] MB: When I think about governmental or policy changes, the big buy-in things that come from the unifying organizations of a nation, or of a population of people. It makes me think about global health, because where there are challenges of hearing healthcare delivery, nearly the entire continent of Africa with a few exceptions face immense disparities and access to any kind of hearing healthcare. The EHDI programs that exists on the continent of Africa, you could count on two fingers, probably. So, it is Ð and what it takes in countries that maybe, low to middle-income countries, to have hearing health care move forward is an agenda. It is a priority, that until a nation, until a government, until a policy-creating body believes in the importance and will be willing to invest in hearing healthcare, it will never receive the funding. It'll never have the sustainability of the programs that are facilitated by policy support. That's the challenge. While we might look at the United States and say, ÒWe're a lot better off, we're a lot further along than some of these low to middle-income countries throughout the globe. We've got mature EHDI systems. We've got opportunities for reimbursable services.Ó We've got a lot of gaps. So, I think, that's an important issue of advocacy and promotion of hearing healthcare on the macroscopic level on policy, is that we need politicians and we need governing bodies to acknowledge the importance of hearing healthcare on the state level, and on the national level. Now, what that will then hopefully do, and we have to be able to stand behind what we may be preaching for, because a lot of politicians will say, ÒShow me the data. Show me the research that what you're promoting, hearing screening, for example, in primary care, which isn't reimbursed, isn't coverable delivery of care. Or diagnostic testing, or hearing aid fittings for adults, you name it. The important things of hearing health care, they would say, ÒShow me the data that demonstrates that this is life-changing. It saves money. It saves lives. It improves the quality of lives, and it's improving.Ó Everything about America is we lack a lot of data that really supports on a larger, very rigorous, generalizable scale. Some of the things that we proclaim is really, really important. The lack of that data is a factor that prevents driving transforming policy change. But that's what we need. We do need more data that really helps to support and anchor the value of hearing screening for example. I mean, this is where my passion is. ItÕs like studying those patients and addressing the patients, way before they ever would come to an otolaryngologist's office or a tertiary academic audiology center. Getting that entry into hearing healthcare through just public health regular screening of adults. Our US Preventive Task Force lacks recommendations for hearing screening, because the data is lacking. We can't be angry about that. We say, ÒHey, what do we need to do to change that?Ó We know it's important for some policy-making organizations such as Department of Health and Human Services, through the Healthy People 2030 initiatives to define what are important prerogatives for health and the future. Hearing screen is a part of it, but it's really only a small incremental increase of what we would like to see change on hearing screening in adults. I guess that long rambling preamble, itÕs me just saying, that data really does drive decisions. Data really does drive programs and policy change. I guess, that's why I have to continue in this field of research, because I feel like unless we keep continuing to study, published, define, describe, and show value of hearing healthcare in multiple different levels, then I don't know that anything will ever change. [00:51:26] DS: Yes, I think that's a great perspective on that. It brings me back to, like I was mentioning before, a friend of mine in Georgia, the way they were able to get the funding for their mobile unit was actually through the Department of Education, because they took the time, they pulled the data, and they looked at literacy outcomes for children with hearing loss in their state, and they were able to tie that back to that loss to follow up right after the newborn hearing screening. These kids, they had a high loss to follow-up rate, and these kids are hitting elementary school. By the time they're in third grade, they're so behind from a literacy perspective that it was greatly impacting their state's test scores and quality of life for adults. They had to approach it from interesting literacy and reading, to get the funding they needed to help for hearing health care, which I mean, there is a connection, obviously, right? But that wouldn't have been my first thought. [00:52:22] MB: Yes, that wouldn't have been your first research study, maybe if you just are thinking about it as an outsider, of let's just define whether they got an appointment or not, or the timing that they got their hearing aid or not, as a clinical outcome measure. But the educational matter outcomes really matter. Yes, if you if you got the right data, and you can talk to the right agency and the right organization, then some pretty exciting things can happen. [00:52:51] DS: Yes. I feel like it's so much more understood by people. Literacy is a word most people understand. They understand reading scores. There's a reading score for students and for schools. It's a lot harder to explain auditory skills, and even language development, I feel like, is a pretty abstract concept to a lot of people who aren't in this field. But if you say, ÒThey don't know how to read.Ó People know reading level, right? There on a first-grade reading level. That terminology is so much more approachable for the general population that I totally see how Ð we have to think outside of the box and how we approach the impacts of untreated undiagnosed hearing loss if we're going to get Ð you're right, it's that public awareness, first and foremost. Our country, we're fortunate that we've had EHDI programs for the last 20 years or so. But in other countries that are still developing, that's step one, is that public awareness of hearing loss and its impact. I think that's a great way to think about that in terms of, you have to start from a place where people understand the problem. You can't ask them to solve the problem if they don't understand the problem in the first place. We're coming up pretty close to the end of our time here. But I did, as somebody who works almost exclusively with cochlear implants, I'm so curious where you're seeing some of the healthcare disparities impact your implant patients specifically? And maybe, what your clinic has been doing, if they're incorporating some of your research into how they approach clinic management or even just front office. How was your research informed, your literal cochlear implant clinical care? [00:54:27] MB: As I said, where I shifted some of my focus intervention of like, how do we Òfix this problem?Ó How do we address it with interventional research or clinical trials? Shifting from the telehealth, tele-whatever to community-based interventions. One of the biggest things that we've utilized is a program called patient navigation, which itÕs a fancy phrase really, that just means a lay person who has gone through the same type of complex health care such as, let's say, a cancer patient who has navigated through chemotherapy and is a cancer survivor, may be employed or trained as a patient navigator to learn some issues and aspects of the logistics of health care and help people to make some connections as needed. But this is like, a navigator from a cancer program gives back and helps another cancer patient navigate through their journey through care. We've studied that. We've published on that and pediatric hearing healthcare and looking that from a diagnostic standpoint, from failed newborn screen or referred newborn hearing screen from the birthing hospital, to use navigation to see if it influences the child having a diagnostic ABR and seen it to be immensely successful. We are studying that more on a larger scale, a state level now, but we're also wanting to study that academically from the diagnostic to treatment standpoint, either hearing aid and or cochlear implant in their continuum of care. In a practical sense, we have learned from and utilized the principles of patient navigation, and have employed and utilized formal positions, such as someone that you might hire like a cochlear implant coordinator, for example. Who is someone who maybe doesn't have a strong background or history in healthcare as a medical assistant, or a nurse, or things like that, or a social worker, even. But someone who feels passionate about the topic and invest in them and say, ÒHey, you're going to be a very valued member of our team, and we want you to tell us what we're doing wrong, what we could do better. But also, to help us navigate these patients.Ó We have had hired, employed navigators through the form of a coordinator, as well as some other community support individuals. But also, even, had unemployed navigators. Not because we're cheapskates. But because they say, ÒHey, I just want to donate my time. If I can ever be of help for your patients and support them and answer questions, let me do that.Ó We have been very quick to influence, to utilize patient navigators, to help influence what patients know, what are their attitudes about cochlear implants, about surgery, and help them to stay grounded in the realities of what we can do and we can't guarantee. Then, also, just to help see them through and support them through the journey. Nobody wants a patient who's eligible, who's willing and interested to fall through the cracks. I mean, we just don't want that to happen. We don't certainly want to force people or coerce people to do anything that they're not wanting or ready to do. But patient navigators, in a practical sense, have really improved our effectiveness, and efficiency at communication. To me, that is the first and most important outcome before we look at word recognition scores, or hint scores, or cochlear implant caseload numbers. Those are secondary, tertiary outcomes. If we're communicating well, then we're successful, and that's really important. That's got to be the most important part of our cochlear implant program. [00:58:33] DS: Wow. We're actually in the process of hiring someone for a position like that right now. I think, that's a really great way to approach how you onboard this person, is you're going to be that community facilitator first. I feel like one of the common themes of our conversation has just been that buy-in aspect of things, right? If we're going to address these disparities, we've got to have buy-in from the patients, we've got to have buy-in from the communities that they're coming from, we've got to have buy-in from the legislators who approve funding. It's such an important thing to communicate these needs of our patients and the needs of our healthcare system in general, when it comes to hearing healthcare. Using your killed your cochlear implant coordinator as a communication facilitator with these families, letting them use their expertise when it comes to communicating with a population they're a part of, and how effective that can be. I think that's a great way to approach that. [00:59:28] MB: We don't belong in communication sciences. If this is our business of dealing with communication, if we're all Ð if we're just about transactions. I mean, we can't be transactional, we've got to be relational. That is the heart of the issue and there's a lot of things that we don't learn, we don't listen to, we ignore about our patients that result in bad clinical outcomes, but also other bad communication outcomes. [00:59:55] DS: Just so you know, you've dropped so many, like, put it on a poster, in a clinic. I don't know if you're coming up with these random, but you've really got a knack for it. They're really powerful things there. I'm trying remember the one you just said. We need to be not transactional. [01:00:15] MB: We need to be relational, not transactional. [01:00:17] DS: That's good. That's good. Put that on a coffee mug with an ear and an implant on it. I'm not even kidding. That's awesome. [01:00:23] MB: I think that was an MBA class, just solely devoted to coming up with meaningless quips. [01:00:30] DS: But itÕs meaningful. I could see how the class might have been meaningless. But no, these are helpful. These are what people take home. Speaking of taking it home, let's take this thing home. It's been an awesome conversation with you. I've really appreciated your time. If there's people listening who have more questions, or are just trying to get their feet wet in terms of addressing the disparities they're seeing in their clinics, in their communities, where could they get in touch with you? [01:00:54] MB: Well, I would love to have interaction and communication, and collaboration has been a secret to success. So, getting lots of different perspectives. But email works great. My primary work email address is a good way to get a hold of me. matthew.bush@uky.edu. I'd love it. I love chatting about this. I would do it for free. I'm glad that I do get paid to do this stuff, but it's a passion of my life. [01:01:29] DS: You've made that very clear and I really appreciate you taking the time. I'm sure the listeners are just going to love this. Thank you again. It's been a great conversation. [01:01:37] MB: Thank you. [END OF INTERVIEW] [01:01:40] DS: That's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education, through SpeechTherapyPD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes. Just head to SpeechTherapyPD.com/ear. ThatÕs SpeechTherapyPD.com/ear. [END] OTE 40 Transcript © 2023 On The Ear 1