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Dr. Ross on Hearing Loss

Redefining the Hearing Aid Selection Process

by Mark Ross, Ph.D.
This article first appeared in
Audiology Online (Nov 2004)

When audiologists began dispensing hearing aids some 30 years ago, our ostensible rationale was that in order to provide a total aural rehabilitative program to our patients, we needed to control the entire rehabilitative process. At that time audiologists would conduct a comparative hearing aid selection, pick the "best" one for the patient, and then refer the person to a commercial hearing aid dealer who would actually dispense the recommended hearing aid. Not precisely the same aid, of course - just the same make and model - and we always hoped that there wouldn't be too much of a difference between the consignment hearing aid we used and the one actually fit to the client. While we informed our patients that they should come to us to discuss adjustment problems, etc., in reality once the patient received the hearing aid from a dealer, it was this person who more often than not assumed responsibility for after care. People rarely returned to us for follow-up.

For our part, we conducted "Aural Rehabilitation" in our University clinics, defined mainly as speechreading classes, for those people whom we could convince to take advantage of our free services. These classes were supervised by MA level supervisors, and conducted by students needing practicum hours for certification. This type of practicum, divorced as it was from responsibility for the fitting and follow-up care of hearing aids, seemed more like an inertial deference to our roots than training content that students would actually employ in their later careers. Certainly, the patients who attended these programs did benefit - in their acceptance and adjustment to the hearing loss, if not in improved speechreading skills. However, insofar as the students who conducted these classes were concerned, this may have been the last time in their career that they ever provided such services.

Our hopes of "doing it all" if we assumed responsibility for dispensing now seems like a forgotten dream. Instead, what we seem to have done is basically adopt the very model we criticized 30 years ago. We do the testing, fit the aids, schedule one or two routine follow-up appointments, and ask the people to "be sure to call if there is any problem". Aural rehabilitation (A/R), even the traditional types of speechreading and auditory training, rarely takes place. In a way, hard of hearing people are even worse off than they were before; now even these traditional programs are less available in non-profit centers - and only occasionally on a fee-for-service basis in any type of center.

I think it is instructive to review how it all began. When the government decided during WW II that they needed to develop programs to rehabilitate servicemen with hearing losses, the military hospitals developed a concept in which the delivery of a hearing aid was just one of the components of a comprehensive A/R program. Their mission was not simply to provide hearing aids to the servicemen, but to try to reduce the overall impact of the hearing loss as much as possible. Some very high quality professionals, representing a number of specialties, pre-planned an aural rehabilitation program that would help prepare the hearing-impaired servicemen reenter civilian life. These planners thought that it would take about eight full weeks for them to accomplish this goal, during which time the servicemen would receive a variety of perceptual and speechreading classes, auditory training activities, vocational and psychological counseling, information about hearing loss, and then also be fit with hearing aids.

Thus, patients who were issued hearing aids also received a comprehensive A/R program at the same time. This residential program was the norm and it was in these settings that the Carhart method of hearing aid selection was first devised. An aid could be selected, tried for several days or even weeks, discarded and a new one fit if necessary. Follow-up testing was scheduled weekly. Adjustment problems were managed as they occurred, new earmolds could be made as needed, and there was always somebody there to discuss problems and issues. In other words, a system was in place in which the hearing aid selection was treated as a component of an A/R program and not an end in itself.

After the war, what the profession did was to separate responsibilities for the hearing aid selection from the rest of the aural rehabilitation program. Since we could not actually dispense the aids, we had to limit ourselves to their selection, usually basing our recommendations on the Carhart procedure. In the meantime, in developing the academic curriculum for the emerging profession of audiology, the content of the A/R course focused primarily on speechreading and auditory training. Hearing aids, psychosocial issues, and coping strategies were mostly ignored in this so-called "Aural Rehabilitation" course. Thus we saw a separation, enshrined in our training programs, between the selection of a hearing aid and aural rehabilitation.

I believe that, as much as possible, we have to return to the original model, in which the dispensing of hearing aids was just one component of a rehabilitative process rather than an end in itself. While we can hardly emulate the residential aspects of the initial military A/R programs, we now know enough about what is and what is not essential so that we can distill its essence into a doable program. We really don't need two full months to effectively respond to the communicative needs of people with hearing loss (though I have to admit that I personally found that interlude a welcome break from military life).

We need to do more than just focus on the hearing aid as some kind of miracle device. We don't want to send a message that the hearing aid alone is a sufficient response to the problems wrought by a hearing loss. It is necessary to deal with all the other issues that accompany a hearing loss, and the most logical time to do this is when the person is being seen for a hearing aid evaluation. But on the other hand, we also need to recognize that people do often require more information and follow-up on issues that specifically relate to the hearing aid.

To attempt to do all of this right takes time, much more than is now routinely devoted to follow-up counseling by the current generation of hearing aid dispensers. Kochkin, in one of his surveys, found that 87% of new hearing aid users received one hour or less of follow-up counseling, while 43% received a half-hour or less of this service. No matter how efficient we are in providing services, this simply does not provide enough time to effectively communicate our information. The focus, such as it is, has to remain on the hearing aid itself, with little time devoted to other issues and problems. This type of practice trivializes the sense of hearing and the role that audition plays in our lives. It simply ignores the importance of being able to efficiently engage in interpersonal communication. A hearing loss is not an ingrown toenail, that can be "fixed" with one or two visits to the doctor.

In brief what I'm recommending is that the hearing aid dispensing process be redefined in a way that while the aid would be a central component, it would not be the only component of a rehabilitative process. It should simply be understood that the hearing aid selection procedure includes (at no extra cost) such a program, in much the same way that we insist on a comprehensive audiological evaluation before we attempt to select hearing aids. We all shudder at the practice of mail-order hearing aids, in which the absence of an audiological evaluation is touted as a benefit. We hold that hearing aids cannot be intelligently and appropriately fit unless we have the information of an audiological evaluation. My point is that we should accept the same logic as it applies to a routinely scheduled short-term group A/R program accompanying the hearing aid selection process.

The decision to purchase hearing aids is not one that hard of hearing people take lightly. Beyond the specifics of where to go and what unit to buy, they've had to first accept the reality of their own hearing impairments. For many people, this is a difficult period and they need all the help, information, guidance and support that they can get. Some hearing aid users expect more from hearing aids than is realistically possible, while others may not be deriving as much benefit as they can confer (e.g. knowing how to use a telephone coil as an assistive listening device, or direct audio input from the audio output of a computer).

During the course of the hearing aid selection process and several follow-up appointments, most hearing aid dispensers will make a sincere effort to respond to their client's informational needs. The reality is, however, that much of this information will be incompletely understood or retained by the hearing aid user. It takes time to assimilate new information, and this simply can't be done in the traditional post-dispensing "counseling" sessions. Additionally, there are inherent limitations in the effectiveness of the one-on-one dispenser-client relationship. There are some areas of need that can best be met in a group setting, where people with hearing losses have an opportunity to learn and share with others who have similar problems. In other words, the interchanges occurring in a group offer advantages and possibilities that cannot be met in individual follow-up appointments. The effectiveness of group hearing aid orientation programs has been repeatedly demonstrated in studies which compared hearing aid satisfaction and use by people who have been enrolled in such programs as compared to those who were not.

While many clients will not accept the option, people who purchase a hearing aid should at least be offered an opportunity to participate in a group post-hearing aid orientation program. Typically, these consist of weekly 1 ½- to 2-hour meetings for about 4 to 6 weeks. While the specific content and outline may vary, the intent must be to provide both an instructional component and time for the emergence of group exchanges. The goals of the group meetings would basically be to foster the interactive dynamics in such a way as to stimulate mutual support and information among the members. Since hearing loss is a family affair, the participation of hearing relatives and friends should be seen as a key objective. A group program is also a good way to communicate the partnership concept that all of us - the professionals, the family, and the patient - are working together on a common objective.

Implementing the Program

I would like to make it clear that I am not making an original suggestion. Some version of group hearing aid orientation programs has been practiced from the time of WW II, when the profession of audiology got its start, and there are many good programs and literature on the topic out there. Whenever the subject of group hearing aid orientation programs is raised, two objections seem to emerge: one dealing with the economic constraints of providing this service, and the other with the apparent lack of interest by clients in the service (few question their potential effectiveness).

Economic Implications

It is estimated that, once regularly scheduled and conducted, no more than two hours per week need be devoted to the program. Ordinarily time is money, but this appears to be one of those propitious instances where time can pay for itself. Consider the following:

  • The incidence of hearing aid returns is likely to be considerably lower for people who attend such a hearing aid orientation program than for those who don't. The problems and unrealistic expectations that come up during the first months of hearing aid usage can be remedied as they occur, before people lose patience and return the hearing aids. The additional time spent in troubleshooting and anticipating (and sharing) "normal" problems can both preclude returns and reduce unscheduled drop-in visits.
  • A hearing aid orientation program is going to translate into more satisfied and loyal clients, and they're going to stick with you when they need hearing aids in the future. Your clients will get to know you as a person as well as the presence behind the audiometer. More satisfied users also mean more word-of-mouth referrals, maybe the most effective marketing strategy there is. The inclusion of family members multiplies the number of contacts and future referral sources. There's always going to be more than one person in the extended family or social circle that has a hearing loss and can use a hearing aid. Make a good impression with the group program, and you may have some of these people come flocking to your doors.
  • During the course of the program, and as a result of group dynamics and the information presented, some monaural users will opt for a binaural fitting. Others will be encouraged to agree to necessary adjustments rather than drop the whole idea of a hearing aid.
  • The program provides sufficient time to display, demonstrate, and dispense other types of hearing assistance technologies, such as assistive listening systems and signaling and warning devices. From my perspective, this is a major weakness in current dispensing practices; we can all agree that hearing aids are necessary, but they are also often insufficient in many instances. In a group, the decision by one person to purchase some assistive device or other accessory, or to sign up for a battery re-supply program, encourages other clients to do the same.
  • While a group hearing aid orientation program should supplement and not supplant individual orientation programs, it's likely that the group meetings may eliminate the necessity of some individual meetings, particularly the unscheduled drop-ins that occur when people are having problems.

Lack of Interest or Need

I sometimes hear hearing aid dispensers claim that a group hearing aid orientation program is not needed because they are already taking "adequate" care of their clients. I don't doubt the sincerity of the statement, but I also don't doubt that this care can be improved with a group program. It is a little self-serving to assert that one's clients don't really need a more intensive follow-up program when one is not available for them. We all seem to get a little defensive when possible procedural improvements are suggested, since this implies a criticism of ongoing practices. We need to keep in mind, though, that the point is not criticism but professional growth; moving to a new way of practicing inevitably implies a movement from a previous practice.

Other hearing aid dispensers claim that they've offered such a group program in the past and that people didn't show up. Yes indeed, this does happen; many clients will not take advantage of all of the follow-up opportunities now offered, even when there is no charge, including a group hearing aid orientation program. But how was the recommendation made? Did it begin with an incidental comment subsequent to the hearing aid selection process, or was the group HA orientation program built into the process from the very beginning? If we define the entire selection process to include the routine inclusion of a group HA orientation program, if we really believe in its necessity and efficacy, and if we communicate our conviction to our clients, people will come. They will follow our professional recommendations. Not everybody, certainly, but since when do we base the inclusion of any recommended therapeutic procedure on the fact that some people choose not to comply? We do what we can for whom we can.

A Caveat

A group hearing aid orientation program is not psychotherapy, and a hearing aid dispenser (whether an audiologist or hearing instrument specialist) is not a trained psychotherapist. We have to know our limitations and when they have been exceeded. The focus of the group should be upon the global impact of the communication problems caused by a hearing loss, and how these can be minimized or alleviated through various devices and appropriate communication strategies. Occasionally, as a consequence of the group dynamics, feelings and issues may arise which transcend the communication focus of the program. This won't happen often, but when it does, the emphasis must be brought back to communication. This is not to say that all expression of feelings must be avoided or diverted. If the conversation veers to feelings of exclusion due to a hearing loss, there is a communication explanation for this feeling, and this is an appropriate topic for group discussion. If, however, someone expresses feelings of intense depression, or starts to recount instances of childhood abuse, this clearly is beyond the scope of the group hearing aid orientation program. Referral to an appropriate specialist is then necessary.

In a perfect world, I would prefer that anyone offering these programs be trained to be a group facilitator and have a background of formal courses in adult Aural Rehabilitation. In this imperfect world, however, there are people dispensing hearing aids with neither the training nor supervised practicum to conduct such groups. The informational component in a group is basically an extension of what now goes on individually, and should present little difficulty. It is when group interactions occur, which is indeed one of the primary goals of such a program, that many dispensers will have to transform themselves from technicians into clinicians. Fortunately, there is a wide array of material available that can help them make this transformation. On balance, therefore, I think the advantages of incorporating a group HA orientation program into every dispensing practice outweigh the disadvantages. The needs of hard of hearing people are immediate, and must be met as well as possible now, not at some distant future date. In other words, it is now that we have to do the best we can in this imperfect world.

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