Dr. Vicky Moore is an audiologist and co-owner of The Hearing Spa in Sarasota Florida.  Along with being an independent hearing aid dealer, she does evaluations for cochlear implants candidates and is an expert programmer for all three major makes of cochlear implants.

New candidates often want to know about how the audiologist does the testing. Dr. Moore discusses the process from the beginning to end and gives a very unique perspective about activation day.

Her interview covers a wide range of related issues and is a good starting point for your research into your hearing journey.

Transcript

Voiceover: Cochlear Implant Basics is a site for candidates, recipients, and their families and friends. If you or a loved one is profoundly hard of hearing, newly deaf, or have experienced sudden hearing loss, we are here to share our stories, and tell how receiving a cochlear implant can be a life changing event. This site is not medical advice, nor is it brand specific. Within these podcasts and videos, you will meet recipients who faced hearing loss situations, and hearing aids could no longer provide comprehension of speech or music. They share the stories of how they lost their hearing, their struggles with growing isolation from their family and friends, their inability to compete in the world of business, their difficulties of navigating air travel without hearing. How the joy of music disappeared, and the panic of not being able to use a telephone to contact 911 to get aid for a loved one.

Voiceover: They will talk about their fears, and the reason they procrastinated to get a cochlear implant, and the reasons they moved forward. How receiving a cochlear implant changed their lives, and the lives of those who surround them. You will meet audiologists, and surgeons, and those who support the deaf and hard of hearing communities. Welcome to Cochlear Implant Basics. Reminder: Cochlear Implant Basics is not offering medical advice. Please consult your own healthcare provider.

Richard: Dr. Vicky Moore is an audiologist and co-owner of The Hearing Spa in Sarasota, Florida. In addition to hearing aids, she does evaluations for cochlear implant candidates, as well as programming for all three major manufacturers. In her interview, she discusses the testing, the cooperation with the surgeon and the manufacturers, and activation from the viewpoint of the audiologist. Her independence gives her a unique perspective in which a new candidate will find enlightening. This is her story.

Richard: Tell me a little bit about your background, your education.

Dr. Vicky Moore: Initially, I was born and raised in England, and then I moved to the States. When I decided to become an audiologist, at the time the field was going through a transition. So audiology at that point was a masters degree, and I decided… because I could see kind of the way the future was going… to get my doctorate in audiology, and there were programs opening up with doctoral degrees. So I have my doctoral degree in audiology, which is a clinical degree with four years for audiology. I have four year undergrad degree in communication sciences and disorders, so a total of eight years of education to do audiology.

Richard: Why did you decide to go into audiology?

Dr. Vicky Moore: So for me it was a little unique. My parents owned a hearing practice, so I kind of worked in the summers, and worked in this field, so that’s how I ended up picking audiology. I was born and raised into it, so to speak.

Richard: So okay, you have this practice in Sarasota. How do clients find you? Why do they seek you out?

Dr. Vicky Moore: So most of my patient base comes to me from referrals, people who are having struggles with hearing. We’ll also get a lot of referrals from other patients, from physicians, people with all different types of hearing loss. I’m unique, because I work not only with hearing devices, but I also work with cochlear implants and do a lot of testing for other types of services through VA and things like that, so.

Richard: A client comes to you for a hearing aid, and they’re struggling. At what point do you say to them, “Let’s investigate a cochlear implant.”?

Dr. Vicky Moore: When we do a full diagnostic testing, and I do the whole diagnostic testing here, we have a sound booth, and we use the latest equipment, do a full hearing test, and we use something called word recognition. Word recognition is the patient’s ability to understand words corrected for their hearing loss. So I look at that, and I look at the degree of hearing loss to determine whether a cochlear implant may be the next step. And then if, during counseling, they’re open to possibly doing a cochlear implant evaluation when I look at that test result, I explain that this may be the next step. And if they’re open to it, we then send them out for cochlear implant evaluation, which is a little different testing.

Richard: The people are very, very interested in what is the evaluation testing for a cochlear implant, so I would hope you would just describe a little bit so that…

Dr. Vicky Moore: Sure. Certainly. So the testing for a cochlear implant, we put you back in the booth. It is word testing using sentences, and we use a test called the AzBio Test. It was devised by the three main cochlear implant companies, and it’s standardized testing for implants. So you’re doing these words, you’re doing them with both hearing aids on, because you have to be amplified and corrected for that test, and then we do right ear only and left ear only. We also do CNC testing, which is another single word set testing, and then we score it, and it’s all scored to normative data that the companies put out, and then we look at those scores.

Dr. Vicky Moore: Depending on insurance, there’s different requirements for that scoring. So for Medicare, typically it’s 40% or below, and we can add noise to that. So some of my patients, if their criteria is that they’re struggling still, but we know that if we add noise, that will help. We add that noise, and then that’s also done with that speech testing.

Richard: Now, there are some of the audiologists I understand do three or four stages of testing. What do you do after that?

Dr. Vicky Moore: So after that testing, depending on what we find, if you’re a candidate at my practice you’d meet with a surgeon. There’s vestibular testing that has to be done, so there’s balance testing, because we need to find out if one side is better than the other. You have to have a CT or MRI, depending on the surgeon that you’re seeing, and then followup with their team to make sure you’re a surgical candidate. So I’m doing the testing to see if you’re a candidate for a hearing device, but there’s two parts to it. You can be a candidate on paper, but health wise, if your health cannot sustain a surgery, then you may not be able to have that CI surgery. So that’s what we have to look at, we have to check all the boxes to make sure that the patient is able to have that surgery.

Richard: Now, how do you determine… because some people go right on to social media, and they say, “I wanted BAHA versus a CI,” and they’re really not clear about the differences. So could you take a few minutes to talk about that?

Dr. Vicky Moore: So commonly, we’ll have patients call that will ask for a cochlear implant evaluation. They’ve never met with a cochlear implant audiologist, some of them have never had their hearing tested, so they’re not sure what it is they need. When we do them, we do the initial evaluation, kind of go from there, and talk to what the patient’s needs are. Sometimes they just need a hearing device, sometimes they have no hearing in one ear and we can look at a BAHA. So BAHA is very good for a patient that has single sided deafness if they have good residual hearing in the other ear. We can do demos of the BAHA, so that’s the bone anchored hearing aid, in office.

Dr. Vicky Moore: So if we have somebody who meets that requirement, we can do that. Some people don’t wish to have surgery, because that is a surgery for that device, so then we look at biCROS or a CROS, depending on what their needs are.

Richard: Talk about the biCROS a little bit, what is that?

Dr. Vicky Moore: So the biCROS is a hearing device where you have a hearing aid on one ear, and then a transmitter that looks just like a hearing aid on the other ear. And then we send the sound from the bad ear with the deafness, so to speak, to the good ear. And sometimes on that good ear you have to have some amplification, so hence the word biCROS. It’s getting some amplification in your good ear-

Richard: From your experience, what kind of percentage of people will the biCROS work for?

Dr. Vicky Moore: We don’t see too many people with single sided deafness, but for those that do, our technology with biCROS and CROS devices now has gotten a lot better. So I’d probably say about 60, 70% of people will end up going that route, as opposed to getting a BAHA. I think maybe I’m unique, because we don’t have a surgeon on site, so my figures may be a little bit skewed because I’m seeing more patients that have either looked at the surgical option, or just don’t want surgery, and they know that I do biCROS or CROS hearing devices. So they’ll come in, but they are successful now with the new technology they have for biCROS and CROS.

Richard: Somebody comes in, and you’ve tested them, and you’ve tried to suggest a cochlear implant, do they go into shock, or what’s the typical reaction?

Dr. Vicky Moore: That’s a good question. Mixed on that one, because sometimes people come in and they have the idea that they may be a candidate for an implant. Sometimes they are completely in shock that they’ve kind of missed their window for a hearing device, and they’re now in candidacy realm for an implant. Not everybody wants to have surgery, some people adamantly won’t even consider it because they feel there’s a stigma with the cochlear implants, so then you have to do what’s best for the patient in the limitations of what they’ll allow you to do.

Dr. Vicky Moore: I always like to show patients what implants look like, because they’re not like they used to be 10, 15 years ago. They’re a lot smaller now, we have the Kanso and the Rondo, which is a lot smaller device versus the over the ear. Some people don’t like the over the ear options. So it’s just trying to overcome what their initial objections are, to see if you can figure out why they might not want to go that route. But with an implant, you want a motivated patient, so you never want to push somebody into an implant, even if they are a candidate, because motivation is part of the rehab process. And if they’re not motivated, then they may not do as well as we would like.

Richard: It’s true that sometimes I’ve worked with people, it may take a year or two until they finally become motivated because now they’re in enough pain of isolation.

Dr. Vicky Moore: That they want to, yeah.

Richard: So what about the borderline candidate? The candidate who is maybe…

Dr. Vicky Moore: With a borderline candidate, depending on the hearing loss configuration, there are options. We do have implants that are hybrid implants, which can preserve some of the low frequency, different companies have different names for them, that give you that acoustical component so you’re not losing your low frequencies. But we are going in and putting in electrical stimulation in the higher frequencies. So we do try to have an open mind on how we can fit patients on what’s best for the patient.

Dr. Vicky Moore: A lot of it goes on how long they’ve been struggling as well, and what their life looks like, social history, what they’re doing. I have patients that are younger, that a hybrid would definitely be the way to go, so we want to make sure we preserve as much low frequency information. So it just kind of depends on the audiogram, patients’ motivation, and what they are expecting from life. We always, here, want to make sure that they’re aware of all their options. I always say it’s my job to make sure you know what your options are. Obviously, it’s up to the patient to decide what fits best, but at least they know they didn’t leave a facility saying, “I never knew I was a cochlear implant option, and that was never mentioned to me.”

Richard: It’s funny that you should say that, because many, many people say, “I’m too old for this,” or, “I’ve been deaf too long for this,” and cochlear implant won’t work. And your experience is what?

Dr. Vicky Moore: My experience, that’s not true. I have many patients such as yourself, and a few others, that have been pretty much deaf over 30 years, and they’re wearing implants and they’re doing phenomenal. I call you guys my rockstar patients, so we have our rockstars that are doing so well with implants, and it kind of, everything in literature that I read when I was in school, and that other people may have seen that talks about how people may not do well with an implant the longer they’ve been deaf, we’re now seeing cases where that is not true. So I always tell people give it a chance, because you can’t be doing worse than you currently are doing if you are not hearing and you are deaf, so it’s definitely a better option than where we are.

Richard: It’s interesting that I never met anybody who said, “I’m not doing well, I wish I had never had it done.” Have you ever experienced that?

Dr. Vicky Moore: I haven’t. We’re fortunate at this center, the patients that we see, everybody for the most part does really well. We have some exceptions to that rule, but still if I say, “Would you rather go back to where you were?” They wouldn’t want to go back to where they were. So even though it’s not perfect, it’s definitely, the reason you’re an implant candidate is because you’re not doing well with your hearing aids. So that’s why you’re in that candidacy criteria.

Richard: Let me ask you another question about candidates that are qualified. Now they have to make a choice, and in my case, I have what I call a document dump. You go to the audiologist, they dump the manufacturer’s brochures in your lap. Do you help the patient choose, or should that be the patient’s choice?

Dr. Vicky Moore: So, a few things that go into that. We work with all three manufacturers, so I like to be able to have access to everything. I have some patients that come in that have done their research beforehand, and they know what they want. Typically, I will advise patients on what is available, what each company’s pros and cons are, so to speak. We also look at the anatomy of the ear, because some of them have smaller processors than some of the others. And then the final part of that, in my mind, is up to the surgeon, because they’re the one that’s putting the electrode in, and different companies have different electrode arrays.

Dr. Vicky Moore: So they may think that one may be better for the anatomy of the ear than the other. But I try to kind of give them as much information as I can to make an educated decision.

Richard: But the surgeon does make a decision for them?

Dr. Vicky Moore: The surgeon sometimes, depending on the anatomy, may say we have to go this route. And they will normally give you a reason. A lot of the time what the patient decides is what the patient gets after we do a discussion. I try to leave it up to the patient to make that decision with as much information as I can get. We have a very active hearing loss association group here in Sarasota, Florida, so I always have people that are potential candidates go to that group. I also try to have them speak to some of my recipients that are working well with the implant, so they can see pros and cons and what they like.

Dr. Vicky Moore: So before they make that decision, it’s not something they do lightly. They typically get lots of good information, and weight it out for themselves.

Richard: They understand they can’t change the decision once it’s implanted.

Dr. Vicky Moore: They do. So that’s the one thing that we do make sure, that once you have a manufacturer, and you pick it, that is the manufacturer that you are with. And although we can upgrade the processor, the external piece, the internal piece, that is what you’re working with. So you have to stick with that manufacturer.

Richard: I’m going to go back to single sided deafness, because that’s become a very hot button topic right now, about cochlear implants and single sided deafness. You want to describe how that works? Why would somebody get a cochlear implant for single side?

Dr. Vicky Moore: So, there’s research studies that have been done for single sided deafness. I am not a study center, but I have had participants that I have sent to studies. So it is something that is recently, like you said, a hot button topic. I have sent people for it, I have not seen it myself with patients, whether they choose to go with single sided for an implant, so I don’t know how much I can really speak to that first hand. But I do know that people are trying it, and it does seem like it is something that maybe the way forward, because we are using better electrodes now, and preserving hearing.

Richard: What about your relationship with the surgeons, and the followup? What happens there?

Dr. Vicky Moore: We work with two centers. We have a center locally that we work with, I also have a center in Tampa that I work with. Both centers we have full cooperation with, which is really nice. So once I find a candidate and I identify him, depending on the candidate they advise me who I would like as a surgeon option, and then depending on what they tell me we kind of go over setting up the appointment with the facility, making sure that we have all the paperwork for them. We set it up.

Dr. Vicky Moore: I do the order forms here in house, and then we send them to whichever facility they decide to go with. And then after that, once they’ve had their surgery, they do a preop first visit, a preop visit, surgery, and then a postop, and then they’re back to me and I see them for the remainder of their care. And then they may see their surgeon annually, or every two years depending on what the surgeon decides. So I take over care from there, and then send reports to the surgeons.

Richard: What about your relationship with the manufacturers? Do they provide support for you, or training, or how do they-

Dr. Vicky Moore: They do. For us to be a certified center, that means we have to have support from the manufacturers. So as I said, I work with Advanced Bionics, Cochlear, and Medel, and all of them we have good relationships with their representatives. I meet with them at least once every quarter, and they give me their updates, I attend their trainings. If we have a software update that gets sent to us, and we make sure that patients then get that update if needed. It’s definitely a very good relationship, a close relationship with those manufacturers, because we want to make sure that if there’s an update or a recall or something, that we know about it.

Richard: Well, do talk about the training you get from them, because I think that candidates would be interested in what kind of training do you get from the manufacturers?

Dr. Vicky Moore: So a lot of the manufacturers provide continuing education units, so we call them CEUs. I would say once a quarter, again, they’re holding an event that we attend to. Either locally, or I have gone to Atlanta, and Colorado, for different events to get training. So whenever a new product comes out, or if they introduce an upgrade, or something like that, they always provide a training, which we go to. And then we do a one day training, or two days, depending on how significant that upgrade is.

Dr. Vicky Moore: They’ll also come in office and do trainings, so I need training and can’t make a training in a different state, they will come in and have representatives who train us. Once we get trained, we get certificates to say that we’ve been trained. When I started doing implants, I’m going back a little bit here, they used to do an online course, which you could complete, and they had different modules before they would allow you to start taking on CI patients. So I have my practicum courses, which I did when I was in school. I also worked with a CI audiologist for a year when I was a graduate student, and then I also passed those practicum courses and modules through the manufacturers, to make sure that I was able to see CI patients.

Richard: Let’s talk about when things go wrong.

Dr. Vicky Moore: Things never go wrong.

Richard: Things… Okay.

Dr. Vicky Moore: Optimistic.

Richard: Okay. Things do go wrong, people are always worried about that, so if you have a recipient who’s saying, “I’m not hearing very well, blah blah blah…”

Dr. Vicky Moore: So occasionally, things will go wrong. Occasionally, there are times when… thankfully it does not happen very often… but we could have a failure. A failure in my world is when everything is working with the processor, everything is connected, software looks good, we’re still not getting sound. So sometimes that means internally, the electrode just stopped working. And as I said, thankfully, I’ve been doing this 12 years, and I see probably over 100 CI patients, and we’ve only had one. So, I have been very fortunate. And that was a known recall by one company. So when all else fails, you have a failure, we bring out the team, because we have a closer relationship with the team. They have to do what we call an integrity check, to check the integrity of the electrode-

Richard: Your team is from the manufacturer.

Dr. Vicky Moore: The team is from the manufacturer, they check everything, and that’s when we determine what is going on. And then at that point, we have to make a decision from there. Sometimes it’s typically a re-surgery type situation.

Richard: From the audiologist’s point of view, activation day, people go online, social media, and they see all these happy faces being activated. What’s your experience as an audiologist? Talk about activation day.

Dr. Vicky Moore: So, activation day has changed due to social media, I will say that. Expectations are definitely very high now with activation, and we also hope and pray that an activation will go that way, but most of the time, realistically when we do an activation, you will hear some sounds. Typically, I’ve been told I sound like Mickey Mouse, Donald Duck, the whole gamut. But you don’t hear speech straight away like you normally did, it’s not something that sounds normal, natural, like you remember. It takes the brain a while.

Dr. Vicky Moore: So occasionally we’ll find somebody who can hear straight away when we activate them, but that is very, very rare. I know online when they do the activation it seems like everything, they just start hearing straightaway, that is not the case. And we normally set things softer, so we typically work through what we call progressive MAPs. I call it my baby step approach. So we don’t turn things up to where they should be straightaway. We start a little softer and then progressively work up to the MAP that we need, and that is what we call the processing strategy we put in the processor.

Dr. Vicky Moore: So we do a little bit at a time, and counsel a patient week one you want to be on your lower MAP, and then turn it up a little bit to your second and third and fourth. So there is a little more to it than just switching it on, and then being able to hear straightaway. The brain has to get used to the stimulation, and that most of the time takes a while. It’s not an instant thing.

Richard: How many return visits do they need after they have activation?

Dr. Vicky Moore: My protocol for visits is we see you for activation, then we typically see you about two weeks later. Then I will see you in another two weeks, then depending on how we’re doing, we will see you at about two months, and then three months, and then every six months after that. But some of that does vary depending on my patient. Somebody who is doing really well, we may not see them as much. But somebody who needs a little extra help, then I may see them more, so we do have that flexibility built in if needed.

Richard: And what about your greatest success stories? What do you have?

Dr. Vicky Moore: So I’m talking to one of my greatest success stories right now, you know. Richard is right here. Sometimes you just get a patient that, even though you think on paper may not do as well as you think they will, they do phenomenal, and Richard, I’m sure, won’t mind me sharing that he scores over 80% on his AZ Bios with his implants. Prior to that we were at zero, so definitely huge improvement. I have a few more patients, similar situation, that have been deaf for a long time and now wear implants, and now can function and hear close to as normal as I think we can get with the implants in everyday life.

Dr. Vicky Moore: So that’s one of the reasons why I do this job, is because I know that for every patient, although everybody is different, we can get them hearing better, and I know what an impact it is to hear on their lives, so they can hear again.

Richard: Talk about your most disappointing activation?

Dr. Vicky Moore: So I had a patient who, and I think some of this does come down to motivation, just was not motivated. Her family wanted that implant to be done, and we did it purely because her family wanted it to be done, but I think her heart wasn’t in it. And so it was sad, because from the get-go, the sounds were not appreciated, she didn’t like what she heard, and then trying to get somebody to wear something when they don’t like the way it is, and have a hard time looking at the future. Because with implants, it’s not an overnight, it’s a long-term goal.

Dr. Vicky Moore: So we always say, you’ll be doing better in about six months. Six months is a long time to wait when you’re eager to hear, and so we could not get that person to wear it for the six months to just commit to the rehab. And in the end, they ended up taking it off at around three, four months, and unfortunately, even though the family was heavily motivated, if the patient is not motivated.

Richard: She wasn’t.

Dr. Vicky Moore: We just can’t do it.

Richard: Are there features you would like to see the manufacturers add to CIs?

Dr. Vicky Moore: Definitely. I would like to see more of the Bluetooth improvements. We have it in hearing aids, where you can use the hearing aid as your mic, so you don’t have to hold your phone up. I would like to see that for implant patients. I’d like for implant patients not to just be committed to one type of cell phone, I’d like them to be able to use an Android as well as an iPhone. I think that should be coming shortly. Automatic features, definitely more with the directional microphones, although we are getting that way. Cochlear has forward focus, we have stereo zoom with AB, but just an improvement on some of the noise reduction. And I do think we’re getting there, but just like everything it takes a little bit of time, so.

Richard: I agree with you. Is there anything you’d like to add to the interview, or that new candidates should know from your point of view?

Dr. Vicky Moore: Definitely when people come in, if they think they’re a candidate, I like them open minded, to listen to what we have to say. Try to always bring somebody with you, because when you don’t hear well, four ears are better than two especially when you’re not hearing well. Definitely take notes, ask your audiologist any question, there is no stupid question. I think sometimes people don’t want to ask because they feel like they should know the answer. There’s nothing that you could ask us that we haven’t probably heard before, and we’d rather you be knowledgeable and know what you’re going in for. So definitely just be your own advocate. Advocate for yourself and your audiologist is there to help you with that every step of the way.

Richard: Thank you so much for time, it’s very informative, and I’m sure that new candidates will find a lot of information they can use.

Dr. Vicky Moore: Thank you for having me.