What is Audiovestibular Medicine?

Audiovestibular  medicine is that branch of medicine dealing with the diagnosis, medical treatment, habituation and rehabilitation of children and adults with disorders of hearing and balance. It is a medical specialty with a Specialist Advisory Committee, based on Royal College of Physicians, determining the training programme.

Most Audiovestibular Physicians work closely with  Otolaryngological Surgeons, much as Neurologists with Neurosurgeons or Cardiologists with Cardiac Surgeons. However Audiovestibular Medicine is a relatively new specialty in the UK (officially recognised in 1975) and at the present time, there are relatively few Audiological Physicians (ca 30) compared with ENT Surgeons (ca. 500) at Consultant level in the UK. The numbers have been  steadily rising with this increased not slowed by the recent changes in the NHS.  The establishment of Audilogical Medicine stems in part from the changing  patterns of the aetiology of hearing and balance disorders, formerly caused predominantly by infectious conditions, but now more due to genetic traumatic  and degenerative disorders very few of which are amenable to surgical treatment.
While certain Audiological Physicians cover all part of the  specialty some concentrate particularly on disorders of children, others on adults. Some are interested more in hearing problems or tinnitus and other in  balance disorders. The training programme for the specialty, however, is designed to ensure that all receive a high level training in all aspects of the  Specialty, and includes the completion of an MSc course in Audiovestibular Medicine in addition to the years of clinical training.

Audiological Physicians  usually work in terms with other Audiological Professionals including Audiological Scientists, Hearing Therapists, medical technical officers, Speech Therapists, Clinical Psychologists, etc

References:

• Career focus, BMJ by Dr O Mahoney
• Careers Focus: Audiological Medicine, 4 Jan 2002 BMJ
• So you want to be a brain surgeon, 2nd edition, 2001, Oxford University  Press

Audiovestibular Medicine

Drs Wendy  Albuquerque and Doris-Eva Bamiou ask if you have heard of this branch of  Medicine that can give Doctors an exciting career as well as a balanced lifestyle. This article  (published in Career Focus, BMJ, 4th January 2002) is an updated, modified version of the original article by Dr Cliodna O’Mahoney.

What is  Audiovestibular Medicine?

First established in 1975, Audiological Medicine deals with the diagnosis, management and rehabilitation of adults and children with hearing problems, dizziness and balance disorders. Although small, the specialty has steadily expanded and  there are now 35 Consultant Audiological Physicians working in Britain, 17  Specialist Registrar posts, one Senior House Officer post joint with  Paediatrics, and one joint Senior House Officer post joint with Paediatric  ENT.  About half the current consultants came to Audiological Medicine from Ear, Nose and Throat surgery. The balance is drawn from a wide range of  specialties including Paediatrics, Neurology, Auditory Research, General Medicine, General Practice and Rehabilitation Medicine. This diversity of  backgrounds has meant that whilst Audiological Medicine has developed as a specialty in its own right, it retains its relevance to, and liaison with, many other disciplines.

Although all medical students and doctors have had undergraduate teaching on topics now encompassed by Audiovestibular Medicine, very few will have been taught by an Audiological Physician. Thus most doctors would have needed a lot of luck to have heard about the specialty, and many may not even be aware of its  existence.

Whilst not immune  from the anxieties of being a time-expired CCST holder shared by Specialist Registrars of all specialities since Calman, an analysis by the Specialist  Registrar Advisor of the Royal College of Physicians has rated the Consultant  Post Prospects to be good in Audiovestibular Medicine. ¹

What do  Audiological Physicians do?

There are three main aspects of work within the specialty : Paediatric Audiology, Adult Audiology and Neuro-otology. The vast majority of patients problems are dealt with on an out patient basis : there are few hospital admissions.

Paediatric audiology includes the confirmation or exclusion of hearing and balance disorders in children, identification of their aetiology and associated pathology, and choice of the appropriate interventions - for example hearing  aids, cochlear implants and habilitation,. This is in conjunction with other  interventions, which will require input from and co-operation with other  professionals, such as speech and language therapists, teachers of the deaf,  educational psychologists and others, in order to minimise damaging social, emotional, educational and vocational effects of the pathology. Hearing loss has profound impacts on the lives of the children affected and their families.   The family’s concerns include questions about the child’s speech development and overall intelligence, anxieties about how best to communicate with and support their child, as well as wishing to understand the underlying reasons for the deafness.  Parents often feel guilty that some aspect of their care has been  responsible and worry that their other children may be affected.  The hearing  impaired child may experience anxiety, identity problems in the teenage years and behavioural difficulties that are directly related to the hearing loss.  The Audiological Physician will need to address all these issues with help from  many professionals.

Another clinical scenario with equally deleterious consequences on the child’s life and development is the presence of a central auditory processing disorder.  Children  with this type of problem usually have normal hearing thresholds and typically present with hearing difficulties in challenging situations.  Identification of  disordered auditory processing will lead to appropriate intervention and educational management that will improve the child’s and the family’s quality of  life.  In all cases, the Audiological Physician’s role is to identify and  correctly diagnose the nature of the child’s difficulties, to decide what specific audiovestibular and other investigations and interventions are needed, to identify or even anticipate related problems, the nature of which will change  over the years, and to ensure that patients are put in touch with other professionals and agencies, as required.

Adult Audiology  : Hearing loss, tinnitus and imbalance are all very common in the adult population, and there is no shortage of patients.  Hearing loss affects 17% of the population², tinnitus is problematic in 10% ³ and dizziness has occurred in between one third and a half of the population by the  age of 60 years.⁴  Adult Audiology applies principles similar  to Paediatric Audiology in the management of hearing disorders in adults. In the management of the adult with hearing loss, the patient’s actual needs will need to be addressed.  These may be different from the doctor’s own preconceptions, as hearing loss may be experienced as a disability leading to severe handicap by some adult patients, or as a cultural attribute that makes  you a proud member of a vociferous, creative minority, such as the Deaf Culture,  by others. The assessment of hearing in the adult learning disabled population  forms another aspect of adult work.

Neuro-otology includes the investigation and rehabilitation of dizziness and imbalance, with  or without concomitant hearing problems, in both adults and children. It also includes the assessment and management of tinnitus and dysacuses. Imbalance can be caused or aggravated by pathology in many different systems. There is good  scientific evidence that the majority of these cases will improve with  appropriate rehabilitation and other medical management, as indicated in each case.  However, the care of dizzy patients who do not have access to an  Audiological Physician can be fragmented, with the patient visiting one hospital  department after another, and no one doctor taking overall responsibility. The Audiological Physician is trained to assess and manage dizzy patients  holistically, ie treating the patient as well as the symptom, and effectively  providing a service that is satisfying for both doctor and patient with this  common complaint.

As well as their diagnostic hospital-based work, most Audiological Physicians are involved with screening and surveillance programmes, such as newborn hearing screening,  hearing screening in children receiving chemotherapy, and screening for  age-related or noise-induced hearing loss. Depending on the particular  interest and background of the individual consultant, and the kind of hospital in which he or she works, some Audiological Physicians specialise entirely in one area, while others span all of the above three fields.  Whichever areas  trainees ultimately choose as consultants, they will be working as part of a  multidisciplinary team which includes audiological scientists, technicians,  psychologists, teachers of the deaf, speech therapists, hearing therapists and clinical geneticists, in close collaboration with other medical specialists such as the ENT surgeons, neurologists, paediatricians and geriatricians.   Audiovestibular Medicine offers a flexibility that enables doctors to carve out  their own niche and to pursue their own clinical interests.  Because of the unfamiliarity of the service for many managerial, and indeed medical colleagues, time must be spent on marketing, i.e. explaining the nature of an audiological  physician’s work, demonstrating the effectiveness of the service and justifying, on the basis of the improved quality of service and outcome measures, the costs  incurred by this specialised service.  Good communication and interpersonal  skills are not just a great asset for dealing with patients.

There is huge scope  and need for basic scientific, technical, clinical, genetic and epidemiological research in Audiovestibular Medicine.  Interest and skill in many types of  research are applicable to the various aspects of Audiovestibular Medicine and  research is enthusiastically encouraged.  The Calman training programme encourages SpRs to take time out for research by enabling them to retain their NTN.

Desirable  qualities in an Audiological Physician

Audiological Physicians need to work well in a team, respecting the skills and expertise of other professionals.  Good interpersonal skills are essential, and interest in embracing and developing appropriate skills to facilitate clear communication with both the deaf and hard-of-hearing populations is needed.  Audiological Physicians need to be good listeners, with an attitude that although not all patients can be cured, much can be done to improve the quality of their life.   A common sense approach to problems is important.

Entry  criteria

Applicants need to have MRCP(UK), MRCPCH, or FRCS (Otolaryngology) and to have completed a minimum  of 2 years of General Professional Training in approved posts before entry into the Specialist Registrar grade.  MRCS is also accepted: however, applicants from this route need to have completed 6 months of general medicine or  paediatrics which includes unselected medical take  Overseas doctors with non-UK, but equivalent, post-graduate qualifications may also be considered.   Clinical experience in paediatrics, neurology, ENT surgery, geriatrics, psychiatry, general medicine or community medicine are looked upon favourably,  whilst an MD or PhD in an audiologically related topic may rarely be an acceptable alternative to a membership or fellowship examination, provided that the candidate has sufficient relevant general clinical experience as well.  The  preferred option is the standard General Professional Training and entry  qualification.

Training structure

Training lasts for up to five years from the time of entry into the Specialist Registrar grade, depending on previous experience.  During this time, the trainee will become  experienced in each of the three fields mentioned above with a view to being awarded the Certificate of Completion of Specialist Training.  Flexible training is welcomed.

Training is  currently organised into two rotations, one between hospitals in Manchester,  Sheffield, Nottingham and Cardiff and the other in the Thames regions.  Trainees are strongly recommended to study for an MSc in Audiological Medicine  (in Manchester or London) on a part-time basis for the first two years of training but can also be obtained by full time study over one year.  Experience  in neurology, ENT, paediatrics (in particular developmental paediatrics), geriatrics, genetics, psychology, psychiatry and ophthalmology is arranged during the training period, in accordance with the training needs of the individual.

Advantages

• Exciting specialty because of the continuing scientific developments in many fields i.e.  cochlear implantation
• Great  diversity of skills required.
• Satisfaction of providing an effective service.
• Scope for  medico-legal and occupational health work.
• Huge research potential in all areas.
• Greater  flexibility than many specialties to develop own niche.
• Plenty of  patients.
• Rapidly  expanding specialty.
• Plenty of  sleep (no on call commitment)
• Little emergency work.

Disadvantages

• Limited  geographical flexibility as a trainee
• Medical  colleagues need to be educated as to how best to use your service.
• No overtime payments as a trainee.
• One of the less glamorous specialities

 Attributes of an audiological physician

• Effective  communication skills
• Good team  player
• Ability to apply problem-solving approach to an individual’s problem
• Ability to accept that you will not cure all patients, but that rehabilitation is highly  effective.
• Well-organised and able to co-ordinate services from technical staff and therapists
• Ability to delegate.

Useful Contacts :

Professor  Linda Luxon Academic Unit of Audiological Medicine, Great Ormond Street Hospital, LONDON WCIN 3JH (020 7813 8107).

Welsh hearing Institute, University Hospital of Wales, Heath Park, CARDIFF, CF4 4XW (01222 743471)

Dr Ewa Raglan, Secretary to The British Association of Audiological Physicians, Great Ormond Street Hospital, LONDON WCIN 3JH (020 7829 7844).

References

1.Mather H .  Consultant Post Prospects in Medical Specialities - an analysis for Specialist  Registrars. 1999
2.Davis AC.  International Journal of Epidemiology 1989; 16:p911-917
3.Coles RRA, Davis AC, Smith P.  Tinnitus:  its epidemiology and management. In:Jensen JH Ed. Proceedings of the 14^th Danavox Symposium: Presbyacussis and other age-related aspects. Stougard-Jensen, Copenhagen 1990.
4.Davis AC, Lutman M. Hearing in young adults study: postal questionnaire. Work in progress.  As cited in Davis  AC Epidemiology. In: Stephens DS Ed. Adult Audiology, Vol 6, Scott Brown’s  Otolaryngology 6^th edition. 1997.