A Need For Knowledgeable, Responsible Hearing System Specialists

1990-11-09

Summary: Hearing aid delivery is currently divided into two arenas, one semi-medical and prescription based, the other, sales based. A new image of a Hearing System Specialist is presented. The role of this individual is as a knowledgeable, responsible guide, who acts "in partnership" with the client, in selecting the best amplification to optimally fulfill the client's needs.

A Brief History

Our industry has evolved as a convergence of two independent fields of expertise: commercial dispensing and clinical audiology. While the differences between these groups are great, and too often antagonistic, each group has been in a position for 5-10 years to apply its technology toward the betterment of the hearing impaired population. Unfortunately the "hearing aid" still has a negative image and industry growth is slight in spite of the entrance of a new wave of commercial dispensers and dispensing audiologists.

Like the ten blind men describing an elephant, each group had a different perspective of the industry, and spent too much time defending their points of view rather than educating themselves to a broader perspective.

Without rehashing painful, old history, or being simplistic, each group had valid goals and more-or-less valid criticism of the other. The dispenser felt he/she was giving the best possible service to the hearing impaired client. Yet with the early aids, inability to control output or provide an appropriate frequency response he lacked both the instruments and expertise to assist the demanding and sound-sensitive sensorineural population.

The dispenser was trained more as a salesperson than an audiologic specialist, and subsequently, criticisms abounded about the dispenser underfitting, overcharging, being audiologically uninformed, using unethical sales tactics, such as bait and switch, taking advantage of the elderly, and handholding instead of fitting. Adding to this long list, there were other complaints that dispensers profited more than audiologists and that people called them their hearing aid "doctor" and assumed that they had the same level of audiologic training as an optician has optical training.

Similarly, the audiological community has tried to find the best method/prescription/instrument to get a hearing impaired individual to hear optimally, in the same way that eyeglasses are prescribed for the visually impaired. But, in relation to this, the commercial dispenser was not always sophisticated enough to appreciate what seemed an idealistic approach by the audiologist. The dispenser complained that the clinical audiologist had unrealistic expectations for successful amplification, that output levels and frequency responses effective in a sound room were ineffective in the real world. To the dispenser, it seemingly took years for the clinical audiologist to convince themselves that two hearing aids were better than one. Controversial conclusions arose from the Harvard Report (reporting a six decibel slope was best for all hearing losses, erasing individual differences), as well as questionable conclusions from audiologic literature (assessing appropriate output levels from experiments in which individuals with both sensorineural and conductive losses were together in the same test population).

As far as ethics is concerned, both groups found dissatisfaction with the other. Unfortunately, people in our society fall in a broad spectrum when it comes to ethical consciousness and practices. Any field is capable of easily generating enough selfish individuals to give the rest of the group a black eye. In my experience with both dispensers and audiologists, the vast majority of us earnestly want to do the best for our clients.

The Heart Of The Problem

The real problem that came between the two groups was that they differed on the basis of their methodologies. The audiologists' methods tended toward "prescriptive" theories, the commercial dispensers were "sales" theory based.

New audiologists, and now physicians entering the field, want to believe that they should be able to measure the parameters of a hearing loss, apply a proper formula, and send the client out knowing that they'll do just fine. Indeed some practicing audiologists may still be thinking that they should be able to prescribe the perfect hearing aid, and that each new aid, real ear measurement device, digital, multiband, ASP, instrument is a step towards the day when we can do a complete hearing aid fitting totally objectively, without having to depend upon much input from the patient.

Unfortunately, when dealing with real people, a multitude of other problems somehow happen to arise with each new client that comes into the office. The solution is called "tweaking," in the hearing aid industry. When the user complains, then its time to creative trouble-shoot and try to figure out what the client doesn't like, readjust the controls, grind on the earpiece, and do whatever is necessary to satisfy the client. It should be mentioned that the authors of the prescriptive formulae are the first to admit that their formulas are only basic starting guidelines.

The problems are always the same - all formulae underestimate the complexity of the hearing loss, the hearing environment, and over-estimate the capabilities of the hearing instruments.

The manufacturing component of this industry has had to make certain choices as to which group they were trying to satisfy, clinical audiologists, or commercial dispensers. Manufacturers who market to the clinical audiological community try to create instruments capable of adjustments to fit the prescriptive models of the audiologists. These manufacturers must present an image of technical expertise so that the audiological community can say, "This is the correct hearing aid for you," even at the expense of having to handhold the patient and tell the client (patient) that they will have to get used to the hearing aid (often called aural rehabilitation in the audiological language).

Many of the commercial dispensers on the other hand are relatively unconcerned with prescriptions. His/her purpose is to satisfy the client with the instruments provided by the manufacturer, and to provide a hearing aid that the client can use and not return. The dispenser often transfers the technological prescriptive responsibilities to the manufacturer, and uses the "sales" method to convince the client that he is getting the best possible hearing aid.

Unfortunately, as said before, other problems show up for the dispenser with each new client that comes into the office. The solution: again "tweaking," readjusting controls, and modifying the earpiece; anything to satisfy the client.

Of course if the hearing aid is not immediately comfortable enough, the dispenser can return it to the manufacturer for modification. The dispenser can also use the line that "Everyone knows that it takes time to adjust to a hearing aid." In the dispensing language this aural rehabilitation is called "handholding."

The manufacturers who market to the commercial dispenser aim to provide a hearing aid that is easy to sell, easy to fit, and minimizes the possibility of a return. These manufacturers have to balance protecting their businesses from returns with satisfying the audiologically unsophisticated desires of the dispensers.

These manufacturers must present an image of technical expertise (as seen through the eye of a dispenser) and an image of creating instruments with user appeal and acceptance. Of course to accomplish this task, certain audiological features that are beneficial to the client have to be sacrificed in order to get looser fits, less feedback, and smaller circuits.

This model of passing the prescriptive decisions to the manufacturer has the same limitations as trying to fit dentures by mail order. The problem for these commercial dispensers and manufacturers is that they underestimate the complexity of a hearing loss and the hearing environment and overestimate the capabilities of both the hearing aid and the dispenser's ability to put out the fires. This method selects for the sub-population of the hearing impaired who will be satisfied with a less-than-optimal fit. The others return their hearing aids to the manufacturer.

Of course in the real world, audiologists and commercial dispensers alike can learn the positive and negative skills of the other. However, regardless of the methods employed, the real measure of success in the field is the number of happy and returning clients. That alone builds a positive image of the dispensing individual, the hearing aid and its manufacturer.

Where Are We Now?

The problem with both the prescriptive and sales models is that they underestimate the complexity of the hearing loss and hearing environment. They do not appropriately balance what we objectively know is needed for optimal amplification with subjective user needs and user acceptance. At the heart of the problem is the desire to oversimplify the problems of the hearing impaired, to reduce the individual to an audiogram, and to pontificate an amplification solution based on a particular paradigm, rather than to deal with each individual's unique hearing needs, situations, and taste.

It is the dispensing professional who is in the position to intelligently interface the academic and technological components of the hearing aid industry with the needs of the hearing impaired individual. The dispenser may choose to pass the "intelligent" decisions to the manufacturer, or to the academician, and use their prescriptive models, or, the dispenser may choose to learn the art and science of intelligently applying the appropriate amplification in the optimal way to each individual client with whom he/she comes in contact.

It is the author's belief that the hearing aid industry needs a new type of Hearing System Specialist and that the focus of this professional is neither merely fitting the parameters of the hearing loss nor pacifying the client with some amplification. The focus is to discriminate the specific hearing problems of the client, the capabilities of the client, and to select with the client the most appropriate amplification that would fulfill the client's need. When a client comes into a hearing aid dispensing facility, the most important thing the client is paying for, is the valuable knowledge of the individual who assists the client in the proper selection of the client's hearing aids.

A "Hearing Problem" Based Method

Such a method is addressed in the Hearing Centers' Network publication, "The Guided Selection Method."

The concept of the Guided Selection Method is simple. The dispenser acts as a knowledgeable, responsible guide who assists the client in selecting the best amplification to optimally fulfill the client's needs. With first-hand knowledge of the client, the Hearing System Specialist is the only individual in a position to make the most appropriate choices (in concert with the client) for the best benefit of the client. But in order to make those choices, he/she must be technologically competent with an understanding of hearing aids, hearing losses, and human nature.

The Hearing System Specialist therefore sheds the image of the prescribing "doctor" or of the "salesperson." Instead he/she becomes the trusted guide who works with the client towards the selection of the best amplification for the client's needs.

The Hearing System Specialist

The following is an outline of some of the basic knowledge and personal qualifications needed in the Hearing System Specialist (HSS).

  1. The HSS must have knowledge of:
    • the physical/anatomical and mental/social factors affecting the selection and fitting of hearing aids
    • audiometric testing of cochlear/central speech processing
    • speech acoustics and environmental acoustics
    • electronics and electroacoustics
    • the mechanico-technical aspects of modifying earmolds and hearing aids.
  2. The HSS must have a method of assessing the needs of a particular client.
  3. The HSS must have the ability to assess the auditory processing capabilities of the client.
  4. The HSS must have the ability to assess the quality and effectiveness of both hearing instruments and instruments used for audiological evaluations.
  5. The HSS must have an ability to think and weigh alternatives and to know what to realistically expect for a particular client. He must have the ability to set up realistic goals for each client.
  6. The HSS must have the ability to motivate and guide a client towards the selection of the type of amplification that is most appropriate for that particular individual.
  7. The HSS must have an ability to listen: The HSS must have the ability to translate client experiential descriptions into acoustico/physical descriptions in order to take appropriate corrective actions.

The HSS should be able to "play" the hearing instrument, like a virtuoso plays a piano, to have the instrument superbly balance the needs of the client. There are all sorts of piano players out there, some with great skill, some with moderate skill, and there are also those who just deliver the piano.

A Need For More Education

Quality Hearing System Specialists are created through an education broader than that currently obtained in audiological programs. The practical knowledge gathered through dispensing experience as well is not enough. Besides the standard audiometric/dispensing course materials, four areas must be addressed in greater detail: (1) understanding auditory processing in the elderly, (2) understanding the acoustics of speech and the noise environment, (3) understanding how to apply the available forms of amplification to specific situations, and (4) how to discriminate the real advances in hearing aid and audiometric instrumentation technology from advertised claims.

Understanding Auditory Processing In The Elderly

Auditory processing has always been reserved for academicians. However, studies of the physiology of hearing and of speech processing are invaluable in assessing the capabilities of the sensori-neural hearing loss individual. Appreciating the factors in both the ascending and descending neural pathways provides insights into what a particular client is able to extract from the acoustic information and how well they are able to focus on the incoming sounds of interest. A mere delineation of the parameters of speech processing can give the HSS an appreciation of what the special needs and capabilities are of his/her SNHL client.

Understanding Speech Acoustics And The Noise Environment

Every room has different acoustics, different generators of sound all with different amplitudes, frequencies, and time and space patterns. Every individual of interest to the client has a different speech pattern. We have just gone through a period when each manufacturer defined "noise" in a particular way and then developed a hearing aid to handle that sound. Again, like the ten blind men describing the elephant, while each could successfully control its particular type of noise, the aid fell short in controlling a vast number of other noisy situations. By understanding the client's environments, the qualities of voice of his/her significant relations, the dispenser can choose amplification tailored to the client's specific needs.

Now with the advent of multiprogram hearing aids, each setting can be specifically tuned to best handle specific situations, for those clients capable of using and appreciating the different amplification modes.

Understanding How To Apply The Available Forms Of Amplification

At any point in time, the HSS has available a smorgasbord of types of amplification differing electroacoustically, in size and shape, in the availability of special features. While no manufacturer can address the needs of all clients, the HSS must know how to choose the most appropriate form of amplification. This requires an understanding of the capabilities and limitations of each form of amplification and how and when to best apply that amplification.

Understanding How To Discriminate Real Advances In Hearing Aid Instrumentation Technology From Advertised Claims

The hearing aid industry is not a science with rigorous reviews and restrictive controls to assure accuracy of data and claims made. Nor is it a large market with a multitude of diverging opinions and critical analyses by competing and independent sources. The HSS him/herself is the one in the position to determine whether the claims about a product or instrument are accurate. He/she must purchase and invest without the benefit of critical reviews. To do this takes a great discriminating ability and a vast knowledge of the instruments, or it becomes a "trial and error" activity. Unfortunately, the errors can be costly for both the dispenser as well as his client.

By any measure, hearing aid dispensing has not been successful. Industry growth rate is not high. User satisfaction is not high. The image of the hearing aid is not high. Many dispensing individuals and manufacturers are struggling. Few people believe the new "noise controlling" claims from either the manufacturers or from the advertising dispensers. The abundance of gimmickry attests to the absence of realistic expectations from the hearing impaired population.

The success and blossoming of the hearing aid industry is dependent upon the approach and methods of the HSS. Successful HSSs, whose goals are optimal individualized fittings, can lead to greater user satisfaction and consequently to a more positive image of the hearings aid in the eyes of the consumer. This should increase sales. In addition, intelligent HSSs should guide the production of better hearing instruments designed to aid the HSS in his/her desire to fine-tune the hearing aid system. This should result in fewer hearing aid returns for the manufacturers, and to a lessening of responsibility for the manufacturer in the selecting of the electro-acoustical characteristics of the hearing aid system. The manufacturer should benefit from that easing of responsibility and the new relationship of service to the HSS.

We have an opportunity to be a new generation of hearing system specialists. As a field we've advanced to have a selection of many forms of amplification. The next frontier is self education and it shouldn't be difficult.

* The purpose of this and the accompanying articles is to present a point of view which hopefully will serve the best interest of all of us in the hearing healthcare industry and our clients. A key consideration is that we have been working hard to fit hearing losses, rather than solve hearing problems. The difference between fitting and hearing loss and fitting a hearing problem is solely in our approach to serving the client, and this slight difference many mean tremendous change in our success. It is hoped that the ideas and methods suggested here might contribute toward the future growth of our industry.

Gil Magilen, M.S., Ph.D.

Dr. Gil Magilen, born in Brooklyn, New York, has a M.S. in Physiology from Long Island University (NY) and a Ph.D. in Biophysics from the University of California at Berkeley. He was a research neurophysiologist studying aspects of neurotransmission at the University of California Medical Center in San Francisco in the Department of Neurology working under grants from the National Institute on Aging.

Deciding to move into an independent practice and following his interest in audiology and mechanisms of human cognition, Dr. Magilen purchased a small hearing aid center in Vallejo, CA in 1982.

He has worked with many manufacturers through the years contributing critical reviews of both hearing aids and audiometric instrumentation.

Dr. Magilen has also developed an office management software, called MacHearTM, using the Apple® Macintosh computer, and has founded Hearing Centers' NetworkTM for the network exchange of practical information within the hearing healthcare community.

Acknowledgement

The author wishes to acknowledge the support of many friends in the audiological and dispensing communities, and also the National Institute on Aging, National Institutes of Health, and U.S. Department of Health and Human Services for providing a grant to study the audiologic problems of the elderly.

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