Starting up cochlear implants

[CTU Surgeon]

Howdy yall.

If I come out of training with great reps in cochlear implants, how difficult would it be to start offering it if I join a private practice that’s not doing it now?

I would assume the following difficulties:
-I would have to find a hospital that would buy a stock supply of CIs where I have PR privileges. I would think it’d be easiest to start with one brand, and I’d probably do AB because I’ve seen the best hearing preservation with them across multiple attendings, and the free hearing aid is nice.
-I would assume most fresher out of training audiologists would likely know how to work with CI’s, and I’d have to find one with some interest? As I understand it, their time with the patients is really where a practice would lose money (the audiologist could make a lot more doubt diagnostics and hearing aids with an equivalent amount of time).

I’m sure there would be other bumps in the road, but I would be interested to hear from anyone who has started doing CIs where they haven’t been done previously. I find them to be a very satisfying surgery, and don’t feel like I’d need an otology fellowship, let alone a Neurotology fellowship, to do them in most adults.

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[Wordead]

I can share some limited experience though this is from a hospital employed POV. It is an undertaking. I feel very strongly about getting a program up and running because there is just no access in my area but it is a heavy lift no doubt. I'm only partway through the process but these are my general thoughts. I hope there are more experienced ENTs out there that have better insight.

1. You absolutely need a motivated audiologist. I do think having a younger fresher out of training audiologist seems like a better fit for this - I think it's really hard to do this alone. They need to be self motivated and trying to help the program grow. It's hard to tackle as a fresh attending unless you're the practice otologist and not dealing with anything else. I'm trying to send mine to the yearly CI conference so they can pick things up and I'm spending my own money as well to attend (max'd out my CME long ago).
2. I don't know about AB or MedEl but Cochlear has a pretty robust support system and will have their audiologists remote in to help your audiologist with the first few programming sessions and troubleshooting. I assume the other companies do too. I don't know how difficult it is to use multiple companies. We never used AB in training so for comfort I would only use what I'm familiar with. I will say that Cochlear has been very helpful.
3. I don't know how it works in private practice but I assume there has to be some similar mechanism to see if it's financially feasible. This is a very, very long process for hospital employed settings. You'll need to negotiate with your partners, especially if it consumes part of the audiologist's time (that could be used to sell hearing aids or whatever) and isn't that profitable in the end.
4. Just as a warning: regarding the surgery - no. You're absolutely right. It's not a hard surgery in non-congenital ears and it's pretty enjoyable drilling a non-chronic ear mastoid. But you can say that for head and neck cancer too. I can do a mandibulectomy or a laryngectomy and necks, throw up a regional flap if needed. I don't do them if I can help it, though, because you need a lot of other robust services - dental, experienced radoncs/medoncs, SLP, etc to really deliver decent care. I feel that if you can't get them high level care, don't do it. So if you don't have a motivated audiologist (or ideally 2+) or you don't know how to do a cochleostomy in highly angulated or obliterated RWs, or you're not sure that you are selecting patients correctly (which I don't think I really grasped as a resident), I would think twice. I think there is going to be a proliferation of CIs in community ENTs in the future but I think it's on us to make sure it doesn't go the way of balloons and FESS where it's overused and improperly selected in a substantial number of patients.

 

[HighPriest]

I can share some limited experience though this is from a hospital employed POV. It is an undertaking. I feel very strongly about getting a program up and running because there is just no access in my area but it is a heavy lift no doubt. I'm only partway through the process but these are my general thoughts. I hope there are more experienced ENTs out there that have better insight.

1. You absolutely need a motivated audiologist. I do think having a younger fresher out of training audiologist seems like a better fit for this - I think it's really hard to do this alone. They need to be self motivated and trying to help the program grow. It's hard to tackle as a fresh attending unless you're the practice otologist and not dealing with anything else. I'm trying to send mine to the yearly CI conference so they can pick things up and I'm spending my own money as well to attend (max'd out my CME long ago).
2. I don't know about AB or MedEl but Cochlear has a pretty robust support system and will have their audiologists remote in to help your audiologist with the first few programming sessions and troubleshooting. I assume the other companies do too. I don't know how difficult it is to use multiple companies. We never used AB in training so for comfort I would only use what I'm familiar with. I will say that Cochlear has been very helpful.
3. I don't know how it works in private practice but I assume there has to be some similar mechanism to see if it's financially feasible. This is a very, very long process for hospital employed settings. You'll need to negotiate with your partners, especially if it consumes part of the audiologist's time (that could be used to sell hearing aids or whatever) and isn't that profitable in the end.
4. Just as a warning: regarding the surgery - no. You're absolutely right. It's not a hard surgery in non-congenital ears and it's pretty enjoyable drilling a non-chronic ear mastoid. But you can say that for head and neck cancer too. I can do a mandibulectomy or a laryngectomy and necks, throw up a regional flap if needed. I don't do them if I can help it, though, because you need a lot of other robust services - dental, experienced radoncs/medoncs, SLP, etc to really deliver decent care. I feel that if you can't get them high level care, don't do it. So if you don't have a motivated audiologist (or ideally 2+) or you don't know how to do a cochleostomy in highly angulated or obliterated RWs, or you're not sure that you are selecting patients correctly (which I don't think I really grasped as a resident), I would think twice. I think there is going to be a proliferation of CIs in community ENTs in the future but I think it's on us to make sure it doesn't go the way of balloons and FESS where it's overused and improperly selected in a substantial number of patients.

Wait until the naturopaths start doing them.

 

[Dr McSexy]

Are hospitals still losing money on a per implant basis? Wasn't sure if the reimbursement ever increased or cost of implant decreases, but thought it was an order of $2-5k loss per implant depending on the contracted rate. There can still be incentive for hospitals to offer these services so that you may expand services or bring in better reimbursed procedures as well(chronic ear, skull base work etc).

I know one of our local hospitals had no interest in restarting the implant service/offering.