Dr. Ross on Hearing Loss
Aural Rehabilitation, "Best Practice" Hearing Aid Fitting, and the Future of Audiology
by Mark Ross, Ph.D.
At the last convention of the Hearing Loss Association of America (HLAA), a woman gave me an article that she thought might be of interest to me, since it related to topics I frequently write about in the HLAA magazine. The article, which appeared in the May/June 2008 issue of Escapees, describes how the writer went about purchasing hearing aids. He began the process in the usual way, by first visiting a “shop that dispenses them” where he was given hearing tests. After the tests came the “sales talk” by the “salesman,” who proceeded to try to convince him to “buy the most expensive devices” that he thought he might sell. Objecting to what felt like an “unconscionable” markup, the author sought to find a less expensive way to purchase the hearing aids that he felt he needed.
He went to the internet and found a location that sold the same hearing aids as those he had tried at the hearing aid shop, but at greatly reduced prices. Since the internet vendor required an audiogram (the shop personnel would not give him the one they had done), he visited a local ENT office where he received a medical examination and an audiogram (covered by Medicare). He then contacted an internet site that sent him a kit for taking ear impressions at home. He sent the completed impressions and the audiogram to the internet hearing aid vendor. A few weeks later, he received two new Siemens Cielo hearing aids, which came with a two year warranty. He declares that the aids fit comfortably and that, according to his wife, his hearing has been “vastly improved.” The total cost was about $1600, compared to (he says) a retail price of $6800. Clearly, he saved a lot of money.
It looks to me that this kind of event is happening more and more often, what with the popularity of internet purchases of all kinds. At least one internet hearing aid site will even arrange a hearing test via one’s home computer (Kimball, 2008a). Presently, the accuracy of such a test is questionable, as is the quality of home-taken ear impressions (Kimball, 2008b); but both these areas are bound to improve in the future and, what with the popularity of open canal fittings, ear impressions will be less and less necessary. And it’s not just internet sites that promise big bargains when it comes to hearing aid purchases. Every day, it seems, I see advertisements in the paper or in TV spots that proclaim major price reductions for hearing aids. The other day I received a direct mail sales letter that promised excellent hearing aids for $299; according to that letter, the company has over “450,000 satisfied customers.” Clearly, price competition is now a major basis for hearing aid sales (when “invisibility” is not being touted!).
The aids extolled in the internet and newspaper ads include all product levels, from entry level digital aids to the latest “premium” models. It is apparent that these appeals must be effective in attracting customers, or we wouldn’t be seeing so many of them. Consumers that respond are simply doing what comes naturally; if the same or a similar product can be obtained at a significant discount, they’re going to go for the less expensive one. I see one discount healthcare catalogue that is advertising four “listening aids,” ranging in price from $9.95 to $39.95! And as much as we would hate to admit it, all of these aids can likely provide “some” help in a few situations … but then again so would a speaking tube or a cupped palm!
The flaws in this course of action are apparent to Audiologists. The goal is not just getting “some” help, but getting the maximum amount of realistic help possible in every situation. Audiologists point out that the proper fitting and follow-up of a hearing aid takes time and expertise, which it does, and that they must be recompensed for their skills and for the time they devote to the hearing aid fitting process. Furthermore, people who require a hearing aid frequently have many questions relating to their hearing loss, as well as communication needs that can best be helped by some other hearing assistive technology (personal FM systems, special telephones, television listening devices, etc.). While it is possible, Audiologists would assert, to purchase hearing aids at reduced prices, this benefit relates only to the product itself and not to the totality of fitting and rehabilitation services that they offer. But this assumes that Audiologists do indeed utilize their unique training and expertise for the benefit of their hearing-impaired clients. When this does indeed occur, the resulting benefits for a client should justify the additional cost, given the importance of hearing for one’s quality of life. Unfortunately, this ideal management scenario appears to be questionable for far too many hearing aid users, who are not getting the quality of hearing aid fitting and follow-up services that they need and for which they are paying good money.
Let us first consider the fitting of a hearing aid. From what I can see, the actual fitting procedures provided by Audiologists are essentially the same as those that the author of the article that I cited received. The audiogram that he sent to the internet vendor was probably used to program the hearing aids, just as would occur when an Audiologist sends a client’s audiogram to a hearing aid manufacturer. According to Lindley (2006), about 70% of hearing aids are fit using this “first-fit” option. This would be fine if (1) loudness discomfort levels could be validly predicted from threshold measures (which is questionable) and (2) different hearing aids fit in this manner produced the same results. However, as Mueller and Bentler (2008) reported, there were output variations of as much as 15 dB when they input the same hearing loss using six different manufacturers’ hearing aids. Getting the output right, as Mueller and Bentler have pointed out – for the third time in fourteen years!- is not taking place. This is not a trivial consideration, as the authors, two of the most eminent Audiologists in the country, remind us. They recommend conducting frequency-specific loudness discomfort threshold measures, a practice also recommended by our professional organizations (both ASLHA and the AAA).
There is much more that can be noted said about the current state of hearing aid fittings conducted by Audiologists, such as the necessity to conduct real-ear measures (a practice routinely followed by only about 20% to 30% of Audiologists), speech-in-noise tests (also relatively rarely done), and the routine administration of pre- and post-fitting self-assessment scales. One need only examine the Guidelines recommended by the American Academy of Audiology (AAA, 2006) to note the discrepancy between a “best practice” approach and what commonly takes place in hearing aid dispensing practices.
It seems to me that our failure to practice a “best practices” approach leads the public to the same perception of the audiological profession that is apparently held by the author of the article. From his perspective, Audiologists appear to be primarily salesmen who do what any salesman does: explain the product and extol its virtues, and then try to sell the one that offers the greatest profit. Aural rehabilitation is dismissed as “hand-holding” by the author of the article. This is our public image and the reason why, I think, the future viability of the profession is endangered. If we’re just about selling some product, it makes sense for a consumer to look for the best price. But if what we’re “selling” is ourselves, our expertise in dealing with the full gamut of the effects of a hearing loss, then the competency and conscientiousness of the Audiologist becomes the most significant factor.
The way to begin is to provide every new hearing aid user with the best services that we can offer, by adhering as closely as we can to the “Guidelines” promulgated by the AAA. There’s a lot there and not everybody will require every procedure, but the possible need for each one should be explicitly evaluated for every client. This course of action would demonstrate to the public than the price they pay to see an Audiologist includes much more than the cost of the hearing device itself. It would begin the process of changing our public image from that of a salesman to that of a true professional. In short, the way to ensure the future of Audiology is to practice what we preach, what our best and most knowledgeable practitioners have been recommending for years, and that is to simply do what we have been trained to do and should have been doing all along.
This article is supported in part by grant #H133E0300006 from the U.S. Department of Education, NIDRR, to Gallaudet University. The opinions expressed herein are those of the author and do not necessarily reflect those of the Department of Education.
American Academy of Audiology Task Force: Guidelines for the audiological management of adult hearing impairment. Audiol Today 2006; 18(5); 32-36.
Kimball, S.H. Inquiry into online hearing test raises doubts about the validity. Hear J. 2008; 18(3); 38-46.
Kimball, S. H. Making earmold impressions at home: How well can consumers do it? Hear J. 2008; 61(4); 26-31.
Lindley, G. Current hearing aid fitting protocols: Results from an online survey. Audiol Today, 2006, 18 (3); 19-22.
Mueller, G. H. and Bentler, R. A. How loud is allowed? It’s a three-peat, Hear J 2008;61(4), 10-15.