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Friday, October 7, 2022

​By Helle Gjønnes Møller*

Self-driving cars, genetically modified foods, wearable health devices. Technology is continually making our lives safer, more efficient, and more convenient. But can tech teach humans to be more humane? Can artificial intelligence help people be more person-centered?

In São Paulo, a team of dedicated academics believe so. They're working on an ambitious initiative to help students at the University of São Paulo, Bauru Campus (FOB/USP) develop person-centered skills using virtual reality (VR). By creating a 3D experience and adding physical stimuli like touch, smell, and sound, the project—dubbed the ImPACT Lab—aims to mimic clinical scenarios, allowing students to virtually put themselves in the patient's or practitioner's shoes.

The Illusion of Being Another
The ImPACT Lab is a transdisciplinary project that promotes immersive, deep, affective, and competency-based learning, supported by digital technologies. A key aspect of the project is based on embodied virtual reality (EVR), which combines immersive VR and multisensory elements to create the illusion of being in someone else's body.

The virtual environment is developed in collaboration with Philippe Bertrand—a pioneer artist in virtual reality. Bertrand has done extensive work to explore the possibilities of using VR for learning empathy-related abilities—his technology is already widely used to explore issues like mutual respect, gender identity, physical limitations, and immigration. “Empathy enables us to learn from others' pain and to know when to offer support," says Bertrand in the article Learning Empathy Through Virtual Reality. “Similarly, virtual reality appears to allow individuals to step into someone else's shoes, through a perceptual illusion called embodiment, or the body ownership illusion."

The Proteus Effect
In virtual environments, users are known to be influenced by their avatars—a reaction referred to as the Proteus effect. For instance, studies have shown that game avatars resembling members of the Ku Klux Klan generate a high level of aggression in the user. Conversely, the characteristics of an avatar nurse or a humanitarian worker could activate sentiments associated with these roles, e.g., empathy and compassion. And this is exactly the effect they are aiming to nurture at FOB/USP, as they prepare a new generation of health care professionals.

Deborah Ferrari and Dagma Abramides are Associate Professors at the Speech-Language Pathology and Audiology Department at FOB/USP and key drivers behind the ImPACT Lab. Ferrari says, “A lot of people don't really understand what it means to be person-centered, but the ImPACT Lab can actually show them what a person-centered and empathetic interaction looks like. With this project, we will help our students develop a professional identity, communication skills, self-knowledge, empathy—and creativity and sensitivity to improve the patient-professional relationship."

A Changing Landscape
The ImPACT Lab was sparked by a number of near-concurrent events. The pandemic had accelerated tech developments, pushing hearing care professionals to consider digital, remote telecare. This caused frustration and concern for many and raised the question of how to be person-centered in an online interaction.

Around the same time, a number of prominent reports were published, stressing and substantiating the importance of person-centered care (PCC): the WHO Rehabilitation Competency Framework, the WHO World Hearing Report, and ISO 21388 for hearing aid fitting management.

In parallel, the Ida Institute launched the Future Hearing Journeys report, exploring the future characteristics and dynamics of hearing care. In the report, PCC was estimated to be the decisive, differentiating factor for hearing care professionals in a tech-dominated future, where they'll compete with new delivery models, like over-the-counter offerings.

Learn more about the Future Hearing Journeys report with The Hearing Journal's recent series.

Future Hearing Journeys, Part 1: An Introduction to Planning for What's Ahead
Future Hearing Journeys, Part 2: Embracing Wellness: The Global Trend Shaping Hearing Care
Future Hearing Journeys, Part 3: The Future of Audiology?
Future Hearing Journeys, Part 4: The Trends and Megatrends Shaping Hearing Health Care

Abramides says, “The scenarios presented in the Future Hearing Journeys report were aligned with discussions that were already occurring in our group—for example, the impact of megatrends and, more recently, the COVID-19 pandemic in the context of a health system that, in our country, is already weakened. The challenges are countless and require a paradigm shift—particularly concerning the performance of the health professional."

To prepare for this changing landscape, the report identified a need for academia to rethink audiology programs. Educators should help students enhance their counseling expertise and see PCC as an avenue for new generations of hearing care professionals to create value for their patients.

No Going Back to the Blackboard
The ImPACT Lab aims to address these points by embracing technology and applying the aspects of it that can help the students be more human-centric. “There's no doubt that digital technology, virtual reality, and e-learning make more sense for this generation of students," says Ferrari. “We don't want to go back to the blackboard because that doesn't appeal to them. We need to embrace technology and make it our friend. It's not the technology per se that interests us; it's how it can help us become more humane.

“As academic educators, it's our job to prepare the future generation for what they're going to face in their daily professional lives. We can't just apply the same methods and rationale with students today because the context is completely different. There are many unknowns, but there's one thing we do know: that the future practitioners will need to prioritize their human skills."

From Dentistry to Medical
At FOB/USP, they are keen to integrate PCC across disciplines. As Ferrari puts it, “people are people." Beyond audiology and speech-language pathology, the ImPACT Lab involves colleagues from the dentistry and medical faculties as well, including professors Mariana Zangrando and Linda Wang respectively from the Departments of Periodontics and Dentistics. Zangrando explains, “Dentistry is one of the health areas that, unfortunately, still has a technicist character. This scenario has been slowly changing thanks to the efforts of groups with a deeper knowledge in the development of skills and competencies. In the discipline of periodontics, the importance of evaluating the patient as a whole becomes even more evident for the achievement of positive outcomes. If, during the periodontal treatment, we don't achieve the so-called 'adherence', i.e., the patient's cooperation in relation to the therapy employed, we certainly will not achieve success."

Wang agrees, “A person's oral health condition is an important indicator of his/her health habits. In recent years, this premise has pushed for a more comprehensive approach, which considers the relevance of treating the person and allowing them to become conscious and active about their own health, going beyond the disease. In this scenario, when approaching a patient in need of dental treatment, the principles of person-centered care have enabled greater patient compliance by including them in the process. To achieve such a goal, appropriate communication skills are very relevant. Thus, dental professionals must achieve levels of technical professional excellence without this prevailing over the center of care, which is the human being."

The Student at the Center
As much as the ImPACT Lab leans on technology, its real strength comes through inclusion of the students and patients in its development. By including their perspectives throughout the development and testing phases, the project team aims to ensure relevancy and usability for all parties. Abramides explains, “An important point of the project is the UX design—the creation of products that provide meaningful and relevant experiences to users. To achieve this, the student is more actively involved, from the conceptualization to the analysis of the solutions, addressed through workshops, focus groups, and consensus meetings with teachers and patients."

Ferrari adds, “We need to be student- and patient-centered to be person-centered. By co-creating innovative educational resources, we enable new forms of interaction between students, teachers, and patients in the construction of knowledge."

The ImPACT Lab is currently in the scoping phase with the first prototype expected to launch in late 2022.

*Helle Gjønnes Møller is a communications specialist and project manager at the Ida Institute

Check out The Hearing Journal's recent Ida Person-Centered Care series.

Thriving Through Reflection
Child-centered Care in Audiology
Reinventing Life: Improving Hearing Rehab with Communication Partners


Wednesday, August 24, 2022

Editor's note: This is an online-exclusive supplement to the August 2022 Audiology Business Handbook​.

Closing the Audiology Gap Press Release.pdf

Eden Prairie, MN - Grason-Stadler, a worldwide leader of clinical audiometric systems, hosted a conversation with Dr. James W. Hall III and Dr. Robert Margolis to discuss the current landscape around the patient-provider gap and the essential need for an automated tool. 

“The population is growing and aging and that increases the need for our services much faster than our profession is responding to it. There are not enough audiologists to provide the services that are needed.” -Dr. Robert Margolis 

Why Automation? 

When Dr. Margolis was the director of the University of Minnesota Hospital Audiology Clinic, he was dissatisfied by the amount of time his highly trained, competent staff was spending on completing pure tone audiometry, which occupied more of their time than any other billable activity. Two experiences solidified his belief that this was an inappropriate use of professional time. The first was with a hearing evaluation performed on a highly educated professional who, after watching him through the window of the sound booth said, “Why do you have to push those buttons?” The second was a meeting with the hospital director who questioned whether ​​​​his staff was productive enough. When he pointed out that they typically were in the clinic until after hours and then took reports home to write, the director offered, “Maybe you need to automate some of those procedures.” It was obvious to Dr. Margolis that the procedure was perfectly amenable to automation, and it set the stage for his automated audiometry solution, called AMTAS. 

“We really need to put a lot of effort into making sure that every graduate of an AuD program in the United States views automated audiometry as an essential component of their clinic.“ -Dr. James W. Hall III 

4 Episodes Unpack Automation and AMTAS 

This video series dives into an engaging, casual, and informative discussion on all things automation in the field of audiology. There are 4 episodes that will discuss: 

• Episode 1: Overview 

• Episode 2: Creation Story 

• Episode 3: Validation, Calibration, and Objections 

• Episode 4: Acceptance and Future 

Watch the 4-Part Video Series 

Click the link below to see the complete 4-episode series and other automated resources.​ 

Monday, August 9, 2021

In this month's Special Issue, Audiology Business Handbook,​ we discuss “all things business”—from strategies to successfully run a lucrative private practice, to financial management of investments/divestments, to marketing initiatives that effectively ​promote your products and services, and more. To set the stage for this discussion, we ask audiology owners and experts critical questions that explore the fundamental query: Is private practice right for me? Read on and share your thoughts. 




Tuesday, June 15, 2021

By Gordon Glantz

Editor's note: This is an online-exclusive supplement to the June 2021 cover story. Read it here. 

While Led Zeppelin may have unknowingly caused hearing loss with its music, one song – “Communication Breakdown"—still resonates like an amplifier from Jimmy Page's electric guitar.

Ironically, there is a major disconnect—or communication breakdown, if you will—between primary care physicians/geriatricians and audiology professionals.

Studies show no more than 50 percent (and that might be generous) of PCPs discuss hearing loss with age 50-plus patients at office visits.

This is the age group where there is an opportunity to be more proactive.

For geriatricians, the numbers are not much better with patients 65 and over.

Well aware of the situation is Dr. Virginia Gural-Toth AuD CCC/A, who is the manager of the Tinnitus, Balance and Audiology Programs at Hackensack Meridian Health JFK Johnson Rehabilitation Institute in Edison, NJ with over 30 years of clinical experience specializing in tinnitus management and amplification.   

“As a profession, audiology needs to be proactive in informing the PCPs of the services we provide and the positive outcomes that are achieved," said Gural-Toth. “For example, the positive impact treating hearing loss has on cognition in the elderly. An opportunity exists for the audiologist to contact the PCPs directly to discuss results as opposed to just forwarding a report."

She went on to add that communication can establish rapport, engage in a question and answer discussion, and is a great educational tool for teaching the PCPs about the benefits of audiology.

Danielle S. Powell, AuD, PhD, has a clinical background as an audiologist, completing her AuD in 2013. She worked in the greater Washington D.C. area for a number of years before beginning a PhD program in Epidemiology at the Johns Hopkins Bloomberg School of Public Health in 2017, where she was a fellow at the Cochlear Center for Hearing and Public Health.

“I can kind of think about two main breakdowns between PCP/geriatrics and audiology," she said. “For many, even other health care providers, as a field, we haven't made hearing and hearing test results very easily understood. Terms like 'mild or moderate hearing loss' are meaningless to others out of context.

“While the attention of primary care physicians and geriatricians towards hearing has grown in recent years, there is, of course, a long way to go."

 Gural-Toth also brought up the issue of consumers directly accessing information about audiology on the internet rather than through their PCP.

She said: “The wealth of information that is available can be confusing to the consumer on how to access services. In light of this, having an informed PCP helps guide the consumer to the correct professional and service."

As for the idea of self-administered tests, lasting 1-2 minutes that patients can take as part of their visits to the doctor, Gural-Toth could foresee better outcomes.

She noted benefits to a quick screen as a preliminary test during a physical to confirm suspected hearing loss and let the consumer know when they need to see an audiologist. 

“However, there are limitations to these quick screens including the type of device used, the way it was administered as well as the noise in the room when it is administered," she said.  “All of these limitations can lead to both false positives and false negatives." 

Also, audiologists on the long list of specialists—eye doctors, dentists, podiatrists, etc. —that were, and still are, placed on hold due to COVID.

“It has been our experience, during the height of the pandemic, that consumers were not returning," said Gural-Toth. “However, that trend seems to be slowly changing. To counter some of these fears, we provided information to our patients as well as offered curbside hearing aid services for those that were concerned about entering the facility."

In addition to age, the role of socio-economics with older people (lack of transportation, etc.) looms large with older patients not seeing the process all the way through.

This can be the case, even if they are referred to an audiologist from a primary care physician/geriatrician.

“As professionals, we are concerned about the social determinants of healthcare that create barriers to patients receiving healthcare including Audiological care," said Gural-Toth, adding that audiology professionals must work toward a common goal of removing these barriers.

She added: “Whichever it is -- transportation, cost of services, or lack of knowledge of our services, working with local agencies for transportation services, offering payment plans as well as working with our PCPs to help the consumers understand our services are just a few things that we can do."

Powell is aware of the same hurdles.

“For parts of the country, simply having access to hearing care can pose significant challenges as there are regions, especially in rural areas, where older adults have to drive extended lengths to reach a hearing provider," she said. “Many other older adults, in general, find navigating the health care system – and Audiology services in particular with all of the steps involved like additional appointments with PCP and ENT – very challenging and therefore get lost in the process."

 Going forward, Gural-Toth views bridging the communication gap as a grassroots effort.

“Audiology has an opportunity to work with their local communities and PCPs to educate them on the services we provide," she said. “On a national level, Audiology has an opportunity to become more involved in their organizations to promote more visibility and support these initiatives that allow for greater access to services."

Powell pointed to campaigns such as “Know Your PTA" as being lifelines, in terms of what a given degree of hearing loss means, as it presents new ideas on ways in which those outside the realm of Audiology and Otolaryngology can better understand hearing loss and communication needs.

“This, in turn, may help educate patients and providers on the impacts of hearing loss and potential treatment strategies," she explained. “Up until recently, however, our research evidence hasn't really shown the importance of hearing loss across other aspects of health beyond communication ability. This will take time to sink in for providers across other disciplines."

Editor'​s note: This is an online-exclusive supplement to the June 2021 cover story. Read it here. 

Wednesday, April 28, 2021

By John Eichwald, MA; Padmaja Vempaty, MSW, MPH; and Yulia Carroll, MD, PhD

NOTE: This article is published ahead online. 

The Noise Control Act of 19721 directed the Environmental Protection Agency (EPA) to protect the health and welfare of Americans from unregulated noise and formed the EPA Office of Noise Abatement and Control (ONAC). In 1974, ONAC recommended an equivalent sound exposure level of 70 decibels over a 24-hour period to protect the public from hearing loss.2 At that time, ONAC also recommended levels regarding interference or annoyance of 55 and 45 decibels for outside and inside activities, respectively. In 1982, ONAC was defunded, transferring the primary responsibility of regulating noise to state and local governments. An analysis of 491 U.S. noise ordinances in 20163 revealed most communities used multiple standards to regulate noise exposure including nuisance, zoning, audibility decibel levels, time of day, and distance.


Investigators reviewed and classified 60 existing community noise ordinances. Searches were conducted on local government webpages or via legal code databases. The 10 most populated U.S. cities were analyzed as well as 50 community noise ordinances randomly chosen from across the nation. Ordinances were specifically reviewed to identify 22 key aspects of noise ordinances. These included five key noise control measures: audibility, time of day, decibel level, zoning, and specified quiet zones to protect vulnerable communities (e.g. hospitals, schools). Ordinances were also reviewed for legal language identifying the entity or agency responsible for enforcement and the penalties, if any.


Of the 60 jurisdictions reviewed, 32 (53.3%) were small, 16 (26.7%) were medium, and 12 (20.0%) were large. Sound sources that were specified by law were identified in all but two (96.7%) of the ordinances. Time-of-day restrictions were found in 55 (91.7%). Zoning restrictions were used in 53 (88.3%) jurisdictions. Activities deemed to be noise disturbances were specified in 46 (76.7%) ordinances. Disturbing the peace was identified in 50 (75.0%), nuisance/annoyance in 42 (70.0%). Audibility, decibel level, and quiet zones were included in 37 (61.7%), 35 (58.3%), and 29 (48.3%) of the ordinances, respectively. Restrictions on vehicles were found in 52 (86.7%) and noisy animals in 31 (51.7%) of the ordinances.

Law enforcement, e.g., the police or sheriff, was identified as at least one of the designated authorities in charge of the noise ordinance in 31 of the reviewed ordinances. Officials in charge of codes, inspections, and other types of regulations were identified in 12 (20.0%) of the ordinances. Health agencies were listed as having authority in 10 (16.7%). Noise control authorities were clearly specified in 4 (6.7%) ordinances. Jurisdictional administration, such as the city council, and other administrative offices, e.g., housing, animal control, public safety, had authority in 20 (33.3%). In 14 (23.3%) ordinances, the authority of regulation was not identified or unclear.

Figure 1. Penalties and enforcement identified in community noise ordinances.

Fig 1.jpg

Among the 60 communities, 40 (66.7%) included fines in their ordinances. Civil penalties or infractions were found in 21 (35.0%). Charges of misdemeanor were listed as penalties in 18 (30.0%), and 6 (10.0%) stated violation could result in imprisonment. In 21 (35.0%) jurisdictions, local ordinances specified that infractions constituted a civil violation. As shown in Figure 1, seven communities (11.7%) had no penalty and no enforcement clauses in their noise codes, two (3.3%) had enforcement but no penalties, six (10.0%) had penalties but no enforcement, and 45 had both written enforcement and penalties. Among the ordinances reviewed, communities with enforcement and penalties written into their noise ordinances were mostly in the South and coastal States. It should be noted that community noise ordinance might not have penalties or enforcement if a superseding chapter for penalties and enforcement supplants multiple ordinances in the code. Some of the ordinances reference a superseding chapter, others do not. Because only ordinances with the word “noise" in the title were reviewed, cross-referenced penalties and enforcement were not identified. Figure 2 shows the number of key noise control measures identified within the jurisdiction's ordinance. All five of the measures were identified in 14 (23.3%) communities, 17 (28.7%) communities had four of the five, and 29 (48.3%) had three categories or fewer.

Figure 2. Number of key noise control measures (pink ≤ ​3, red = 4, and maroon = 5). Noise control measures: plainly audible, time of day, decibel levels, zoning, and quiet zones (e.g. hospital or school).

Fig 2.png


Exposure to loud sounds puts millions of people in the United States and across the globe at risk not only of hearing loss, but several highly prevalent health effects including ischemic heart disease, hypertension, injuries, anxiety, sleep disruption, stress, and cognitive impairments.4,5,6 While three of four of the jurisdictions reviewed cited annoyance, nuisance, or disturbance as a primary purpose for the noise control ordinance, only slightly more than half cited health as a primary purpose.

Almost all jurisdictional noise ordinances reviewed included time-of-day restrictions, demonstrating that communities recognize excessive noise at certain hours can be more problematic. Half of the jurisdictions listed the police or sheriff's department as the enforcement authority. Only four communities had a noise control officer, or a specific noise control authority identified. As a result, noise enforcement relegated to the responsibility of police departments may not be prioritized as a violation. Of concern is the finding that nearly one-fourth of noise ordinances did not have an enforcement body identified, although a general enforcement statute may be listed elsewhere in the local code. If a community has a noise ordinance and a disturbing the peace ordinance, it may be easier for law enforcement to cite disturbance of the peace, which is likely more subjective and has less stringent legal requirements.

Although the number of key noise control measures in a jurisdiction reveals the variety of methods used, it is not necessarily a measurement of its effectiveness. A community could potentially include all five of the controls but find them ineffective, confusing, and difficult to enforce. Objective measurements might not be available for noise monitoring, or enforcement officials may not have the necessary training to properly utilize noise measurement equipment. In such situations, enforcement officers might be more likely to cite a more subjective ordinance, such as disturbing the peace. This review did not account for noise regulations included in ordinances related to disturbance of the peace, land use or zoning, and in other parts of the local code. These regulations are not always cross-referenced in the noise ordinance.

To help offset the harmful effects noise may have on health, ordinances can incorporate quiet zones into communities. Quiet zones, or noise-sensitive zones, can be designated in areas that should have a lower threshold for noise, such as areas with hospitals or elderly care homes. Issues such as sleep disturbance affect the elderly and persons with chronic illness.7 Schools and daycare centers should also be in quiet zones, as even moderate traffic noise does not detract from academic performance.8


Because local jurisdictions do not have up-to-date federal noise guidelines to follow, local noise ordinances reviewed in this article are varied in terms of their noise control strategies, enforcement, and penalties. With up-to-date guidelines that consider the health implications of noise and recent noise monitoring technology, jurisdictions might be better informed and could follow a set of common standards. State and local governments might consider using the World Health Organization's Environmental Noise Guidelines for the European Region9 as a framework when crafting their legislation to protect health from exposures of environmental noise.

​ABOUT THE AUTHORS: Mr. Eichwald is an audiologist within the Office of Science at the Centers for Disease Control and Prevention (CDC) National Center for Environmental Health (NCEH). Ms. Vempaty is a Public Health Analyst for Policy and Issues Management in the CDC/NCEH Division for Environmental Health Science and Practice. Dr. Carroll is the Associate Director for Science at the CDC/NCEH Division for Environmental Health Science and Practice.

ACKNOWLEDGMENTS: The authors thank Monica S. Hammer, JD and Les Blomberg, MA for their expert advice on noise ordinances; the in-kind support of the CDC Center for State, Tribal, Local, and Territorial Support, Public Health Law Program; and Mahad Gudal, a Morehouse College IMHOTEP program summer intern.

DISCLOSURE: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry. 


  1. Noise Control Act of 1972, 42 USC. §4901–4918 (1988). Available at: Noise Control Act of 1972, 42 USC. §4901–4918 (1988). Available at: Accessed April 26, 2021.
  2. United States Environmental Protection Agency. Information on levels of environmental noise requisite to protect public health and welfare with an adequate margin of safety. No. 2115. US Government Printing Office. EPA Publication No: 550976003 Published March 1974. Accessed April 26, 2021.
  3. Blomberg, L. Preliminary results of an analysis of 491 community noise ordinances. Paper presented at: NOISE-CON; June 13-15, 2016; Providence, Rhode Island. Accessed April 26, 2021.
  4. World Health Organization. World report on hearing. Published March 2021. Accessed April 26, 2021.
  5. Hammer MS, Swinburn TK, Neitzel RL. Environmental noise pollution in the United States: developing an effective public health response. Environmental health perspectives. 2014;122(2):115-9.
  6. Münzel T, Schmidt FP, Steven S, Herzog J, Daiber A, Sørensen M. Environmental noise and the cardiovascular system. Journal of the American College of Cardiology. 2018;71(6):688-97.
  7. Kim R, Van den Berg M. Summary of night noise guidelines for Europe. Noise and health. 2010;12(47):61-63. doi:
  8. Wilensky J, Winter M. Quiet zones for learning. Human Ecology. 2001;29(1):15.
  9. World Health Organization. Environmental noise guidelines for the European region. Available at: Published 2018. Accessed April 26, 2021.