Critique of the Hearing Healthcare Industry (1993)
The state of hearing healthcare in America is the result of problems with all participants in the hearing healthcare community: audiologist, physicians, manufacturers, the trade journals, and dispensers. In my opinion no group should be singled out; all should be provided with an opportunity for growth.
The following is a summary of the problems as related to each segment of the hearing healthcare community.
It goes without saying that at any point in time the quality to which we can fit hearing aids is a function of the current limitations of our knowledge and technology. Clients continually say to me "We can put a man on the moon, why can't they make a hearing aid that works?" I wish to show how simple research mistakes, and the inability of researchers to recognize and correct them, were the major contributors to the poor development of the hearing aid industry.
I will demonstrate the mistakes in relation to the segment of the community which should have seen the error and should have created the solution.
There are two problems with the audiological community, one an ontological problem regarding the development of the basic audiological concepts, and the other a practical problem regarding audiologist's current capabilities for dispensing hearing aids.
Ontologically there have been two types of mistakes in the development of audiology in relation to hearing aid dispensing. One is a mistake of method, the other mistaken assumptions. First I will discuss the mistaken methods.
The academic and clinical audiological community have developed most of their audiologic hearing aid concepts by the method of "trying to maximize word discrimination in sound proof booths" performed on clinic patients or college students. The results of such sound room methods led to hearing aid characteristics and settings that were impractical for patients (1) once they were outside the sound room, or (2) if the patients did into fit the profile of the clinical patients being tested.
How can such obvious fitting problems go uncorrected for so long by the academic audiological community? Historically, audiologists are academics and clinicians and not dispensers. Identifying more with the university and medical communities, they sought objective data modeled after the scientific community and defined their relationship to their patients modeled after the medical community. In addition, audiologists worked more with children, conductive losses and the more severely impaired populations. It should be noted that this population makes up about 10% of the clients who walk into hearing aid offices. Mild-moderate, sensorineural hearing loss individuals comprise the vast majority of individuals seeking hearing aids. These individuals (seen more by dispensers) are much more sensitive to loudness, occlusion, distortion and are at least able to be fit with the concepts developed in sound room settings.
Why were sound rooms used? For hearing testing purposes they were invaluable. They controlled all of the environmental sounds, and controlled-noise conditions could be introduced and studied individually. However, for fitting hearing aids, they are the polar opposite of the appropriate conditions. They eliminate the great variety of uncontrolled sounds the patient will be experiencing in the real world and lead to an oversimplified understanding of the problems with which the patient will be dealing.
The invalid concepts obtained from sound rooms were
- excessive loudness levels for the setting of hearing aids for the sensorineural hearing loss population;
- excessive occlusion of ear canals for milder losses;
- a decade long argument on the appropriateness of one or two hearing aids for a patient;
- the conclusion that one prescription can fit most hearing losses (the Harvard Report);
- a shifting of the responsibility for the fitting to the client (Carhart method);
- the disfavoring of compression technology;
- the development of a disregard for the patient's subjective experience;
- the conclusion that up to 20% distortion in a hearing aid was not a major concern for the hearing impaired;
- the false notion that hearing aid fittings require large scale post fitting aural rehabilitation; and
- the misunderstanding of the variability in what a patient calls their most comfortable listening level.
It comes as no surprise that hearing aids fit using these invalid concepts when worn outside the sound room would be too loud, make the patient feel plugged up, would not handle complex noise environments, etc. and would soon end up in dresser drawers. Now, I would like to go on and discuss the assumptions that were made that were false.
The first mistake was that the audiologist operated on the premise that they should be able to perform a totally objective fitting. That they should be able to fit a patient "without the patient even having to raise their finger," as I've so often heard at seminars. In sound rooms audiologists controlled all the variables while, in practice, the instrument would be worn in a totally uncontrolled environment. To this day this is the standard operating assumption. This led to the inability of the clinically trained audiologist to hear the needs of the patient. They would not listen to the subjective experiences of their patients.
The second mistaken assumption by the audiologists was the belief that they could apply the same concepts developed for the fitting of severe hearing loss individuals to those individuals with mild hearing losses, with minor modification. This is comparable to prescribing thick heavy eyeglasses to individuals with a need for mild reading glasses. Those individuals with sensorineural hearing loss were consequently overfit (too loud, too occluded, uncompressed, excessive low frequency, etc.) and of course their hearing aids were put in the drawer.
The third mistake was the use of aural rehabilitation to make up for poor quality audiometric fittings. Patients were told that they had to adjust to hearing aids, rather than the audiologist taking the time to determine how to adjust the hearing aids to the client's needs.
Consequentially, these invalid academic audiological concepts had deleterious effects on both the manufacture and dispensing of hearing aids. They also were the source of much of the animosity between the audiologists and the dispensing community and certain manufacturers.
Practically, are audiologists more competent to fit hearing aids? The answer is not as apparent as one would guess. While audiologists go through a more rigorous selection process and have excellent professional training in diagnostic audiology, they receive very little training in the selection and fitting of hearing aids as part of that program. Moreover the training they receive is primarily from academics who do not have the experience to understand the practical problems of selecting and fitting hearing aids. And as mentioned above, many of the fitting concepts young audiologists learn run counter to good quality fittings.
Currently audiologists still advocate prescriptive fittings based upon objective audiometric data. In a discussion with an author of one of the audiological fitting methods I was told, "I know these formulas will not provide beneficial hearing, but I have to tell these kids something, at least they won't hurt anybody, it's a starting place and the smart ones will learn." I agree with that. These formulas are a starting place and only that. No one should believe that neatly printed electroacoustic reports have any direct bearing on whether the patient will wear the instrument outside of the sound room.
In my experience, the average dispensing audiologist has a sincere interest in helping the hearing impaired. Good dispensing audiologists, like good dispensers, having to satisfy patients or lose the sale, learn to overcome the client's problems and to select better amplification characteristics. The academics will then declare the discovery of new audiological fitting methods that work better than the "old" dispenser fitting methods.
The medical community has neglected hearing problems in the elderly. The source of the problem is that the physician cannot treat or cure sensorineural hearing losses. This has resulted in a phrase I hear regularly in my office, "My doctor told me nerve deafness' cannot be helped." One of your staff should sit in my office and listen to the disbelief of my clients, after being properly fit with a hearing aid, as they say, "I can't believe my doctor said I couldn't be helped."
Physicians are the gatekeepers. Why don't they open the gate? Patients should be screened for hearing problems routinely, since according to surveys 50% of males and 35% of females over 65 years have hearing losses. Not screening children would be totally irresponsible. Further, when it is obvious that a patient has a hearing loss, physicians should refer these patients to an audiologist or dispenser. This, physicians rarely do.
What is the missing link between physicians and the hearing healthcare community? Lacking adequate knowledge of both hearing impairment and possible hearing aid benefits, physicians are reluctant to precede referring patients in a direction that may have unsuccessful outcomes.
Manufacturers have to sell hearing aids to survive and they find solutions to assure survival irrespective of the knowledge level of the audiologists or the competency of the dispensers. To solve the problem manufacturers learned to create the small hearing aids people will buy and that the dispensing community can sell. The public get what they want, but at a cost of reduced hearing quality. They are duped into believing the advertisements that these hearing aids are an improvement.
The dispensers are duped as well. Manufacturers advertise to the dispenser that the quality of their hearing aids are good, by creating "scientific-like" articles and explanations to justify their instruments. This misleading justification of the canal aid and the new circuitry that goes into them leads to the conclusion for the dispenser and the public, that the canal aid is generally a better type of unit.
What is often called manufacturer support is actually the manufacturer usurping the responsibility for the hearing aid fitting from the dispensing individual. I can send to any in-the-ear hearing aid manufacturer, two ear impressions, and four Xs and four O's on an audiogram sheet, and in return I can obtain two hearing aids, without any adjusting screws on them, to sell at any price I wish. This action requires little knowledge or training on my part. Manufacturers proudly claim that they have the computers and expertise to appropriately select the performance characteristics of the hearing aids for my client without my having to get involved. They create hearing aids with minimal adjustability and compromise the quality of sound in order to reduce the possibility of the aid being returned.
In my office I must constantly overcome my client's misunderstanding that they want the "new, modern, high tech little hearing aid that is almost invisible." I fit about 80-90% behind-the-ear hearing aids. They are cosmetically successful and, more importantly, serve the clients' needs. My clients are shown the clear distinctions between the different types of hearing aids and then they choose which is best for them, based upon their experience of the differences and my guidance.
In conversations with manufacturers it is their opinion that the average dispenser or dispensing audiologist does not have the technical background to expertly fit a hearing aid. For the manufacturers to be successful with the current delivery system on a large scale, they have resigned themselves to designing instruments they think the current dispensing system is capable of fitting. They are in a catch-22 and will stay there until they have knowledgeable dispensers to whom to sell their instruments.
The trade journals have a co-dependency relationship with the manufacturers. They do not publish papers that are objectively critical of manufacturer products or that give an objective analysis of the status of the industry. While this is often a tradition in trade journals in sales industries, in the semi-medical hearing aid field it does not provide the type of information exchange dispensers need to learn how to knowledgeably select and criticize instruments. Such an objective arena has not been available anywhere in the industry.
Audiological journals as well do not provide objective research on hearing aids. It has not been until recently that articles on hearing aids have started to appear. Hearing aids have always been alluded to as being "beneath the dignity" of academic audiologists.
While it is true that Miracle Ear and Beltone attract, very often, inappropriate individuals into the hearing aid profession, with the resulting misleading ads and unethical activities, this is not the problem. It is the symptom of an underlying cause that needs rectification.
Given all that I have introduced above regarding the invalidity of the audiometric concepts, the physician keeping the gate closed, the manufacturers usurping the responsibility for the hearing aid fittings, and the absence of an objective arena to share knowledge about methods and products, no wonder the delivery system is in difficult straits and is prey to corrupt individuals.
Dispensers are as diverse a group of individuals as one can find anywhere. There is an old breed leaving and a new younger population entering. Generally dispensers can be roughly classified into three categories: sales-oriented, technology-oriented, and people-oriented. While they may lack knowledge of audiology, they often have electronics or engineering or social skill backgrounds. Often hearing impaired themselves, they have the compassion to work with the client until a satisfactory result is obtained.
While most dispensers are interested in finding real solutions for their clients, there is definitely a sales-oriented population who are more interested in profit than in service. In addition to this, great variation in state licensing and lack of enforcement of existing laws has created an inconsistent quality of care across the nation.
However, recently there has been a disproportionate degree of abuse fired at the sales practices and knowledge of the dispensing segment of the "hearing healthcare community". While such criticism, as I've said, is not totally unjustified, it is myopic and being exploited by others who are as much at fault. No segment of the hearing healthcare community has the moral high ground, nor deserves the right to wear the white hat for the hearing impaired.
As I see it two things need to be done with the dispensing community. One, the bad apples and the bad practices need to be eliminated. Two, the dispensers and the industry need an objective arena for evaluating and criticizing hearing instruments and techniques. Dispensers need access to an educational tract to allow them to become knowledgeable, responsible professionals.
Advertising and Hearing Aids:
Given the current image of a hearing aid, advertising is difficult. After all, nobody wants a hearing aid. Clients are told by physicians, and by friends who purchased hearing aids that they do not work. With great reluctance they succumb to the prodding of a relative and impulsively respond to the next unbelievable hearing aid ad they see. The more unbelievable, the more successful the ad. With my ads as well, I've found, "the more informational content, the lower the response".
Why do hearing aids get such a bad rap? Hearing aids provide only limited benefit. 1- Not all types of hearing loss can be addressed successfully. 2- Too often what appears as a simple problem of hearing is complicated with the addition of a reduced ability of these individuals to process speech information. Hearing aid purchasers often do not get this explained to them because the dispensing individual is not capable of assessing to what degree the individual has such a problem. 3- Clients are misled to unrealistic expectations.
In summary, the problem with the hearing healthcare community is that there really is no "hearing healthcare community". No segment communicates with, nor respects, any other, and each seeks to advance its own interests. And, more fundamental to even this lack of communication, the whole community is operating on a mistaken basis of knowledge from which it is attempting, with unsuccessful results, to adequately serve the hearing impaired population.
I believe that if the responsibility for the quality of the hearing aid fitting is placed primarily in the hands of knowledgeable dispensing individuals, then the industry will evolve to become a responsible and successful branch of America's healthcare system. Now there is an opportunity, by way of new regulations and guidelines, to direct all segments of the industry towards greater competency in caring for America's hearing impaired.