With the deluge of new digital and directional technologies, the professional dispensing community needs to understand and ask more questions about the approaches and strategies that we are using. We are now firmly entrenched in the Digital Age. And the problem with approaching digital instruments from an “analog mind set” is that you can only get an “analog” result. When we do this, the patient is short-changed by our own limitations. The unfortunate result of this approach is that we, at times, may be delivering some of the most expensive 1985 fitting technology money can buy.
I have a growing concern that, collectively, the hearing care field is falling further and further behind the “learning curve.” While I don’t pretend to be the only one concerned about dispensing professionals’ ability to keep up with technology, it does often seem that we, as professionals, are increasingly pretending that “if we don’t talk about it, it isn’t true.”
This is the time of digital instruments and digital equipment. It is the time of “software” solutions rather than of “hardware” solutions. It is a digital age in which the options for addressing a hearing loss, in many cases, are limited only by the imagination of the dispensing professional. However, the major problem with approaching digital instruments with a traditional “analog mind set” is that you can only get an “analog” result. When we do this, the patient is short-changed by our own limitations, rather than those of technology or the field’s knowledge.
Another unfortunate result of approaching digital instruments from an analog mindset is that we, at times, may be delivering some of the most expensive 1985 fitting technology money can buy. It should be immediately recognized that this is not because we want to provide less-than-optimal amplification to our patients. Instead, it is because we are afraid, and being afraid, the natural human reaction is to snuggle tighter into the comfort of the proverbial “box” that we should be trying to think our way out of. We are sometimes confused and worried about the pace of dispensing technology, and being afraid, we fall back upon the old methods, with the old mind sets — and then do not understand why these old methods don’t produce optimal results in the modern digital age. Essentially, we are thinking less and less about more and more.
After a recent seminar, I was asked about fitting hearing instruments without compression capabilities. Frankly, at this point in audiologic history—a time in which we have wide dynamic range compression (WDRC), multi-band, programmable hearing instruments—I’m not sure why someone would wish to go back to a basic linear fitting unless the client absolutely insisted upon it. In fact, it can be argued that, at least at this point in our field’s history, the use of WDRC multi-band technology is far more important than digital technology. Therefore, only partly in jest, my response to the question was that there is a word for someone who routinely fits linear non-compression aids: “defendant.” It is important that dispensing professionals insist on compression hearing instruments for patients who have a sensory pathology and a likelihood of tolerance/recruitment problems (ie, the majority of patients we see). This technology can protect both residual hearing and “the best interests” of the patient. Additionally, because dispensing professionals are an integral part of the hearing healthcare team, we should also abide by the prime directive of the Hippocratic Oath: “First, do no harm.” Compression hearing instruments help us to fulfill this mandate.
Embracing Questions
The modern capabilities of digital and WDRC multiband hearing instrument technology require new questions, with new answers, based on new tests—both now and in the days to come. The answers aren’t hard; what is hard is learning to ask the right questions! This is the area about which we cannot settle for the “old ways” of thinking. For example, if you are going to fit a hearing instrument in which the frequency response goes out to 6000 Hz, then it is imperative that you ask yourself about the capabilities of the patient’s ear out through 6000 Hz. Again, the most important part of the process is not about the answers, it is about the questions.
This may seem intuitively obvious. However, time after time I see patients with a “standard” audiogram and a targeted “Best Fit” which does not live up to the “Best Fit” billing for that particular individual. It is essential to measure thresholds for frequencies, MCLs and UCLs for those same frequencies, then convert those measurements into dB SPL in order to equilibrate the test results with the hearing instrument parameters.
When we have these measurements (with or even without the real-ear SPL readings at the face of the tympanic membrane), we have (at least) a basis for working with the patient. Our goal is to maximize the communicative efficiency of the patient by optimizing his/her residual auditory area. In order to attain this goal, we have to know not only about the peripheral hearing capacity for tonal stimuli, but also about the central processing for speech and for binaural hearing. More questions! More time! How much time do you have? I submit to you that you have as much time as it takes to do the work right the first time, and not one second to do it over.
Learning and Re-Learning
Essentially, any field that is dependent on our knowledge of the human body (and particularly, the senses) requires that we learn something well, then in response to new scientific findings, revise or replace that knowledge accordingly. Our use of compression, new fitting rationales, multiple microphones, etc, are examples of this. Further, I believe that the day will come when we will discover the lunacy of 5 dB measurements calibrated in dB HL with 2.4 dB of “freedom” on either side of each increment. This cannot be an adequate predictor of appropriate hearing instrument fitting—which is done in dB SPL with no degrees of freedom. We will discover that the idea that “intermediate frequency thresholds” are always located along a straight-line connector between adjacent octave or half-octave points is simply an example of accepted group hallucination. We might even make the “leap” to understand that you do not hear with your ears, you “hear” with your brain. Therefore, we need to understand how the brain decodes acoustic signals during the process of what is generically called “hearing.”
We will learn that we have to begin to understand binaural summation and the effects of the differential “time of arrival” of the signal. We will learn about the delayed auditory feedback (DAF) effect when a 0° azimuth signal arrives in each hemisphere differentially, and how to test for it. We will learn about the effect when the difference in these arrival times exceeds a very narrow time-frame. We will develop new materials to evaluate the prosody of speech and its timbre. And we will have to look far more closely at consonant-vowel and vowel-consonant transitions. Again, it is not about the answers; it is about the questions.
Many times the questions lie in the logical progression of the technology itself. For example, computers and the Internet have opened up a whole new world of possibilities. We are already seeing demonstrations of “holographic” impressions sent from the computer in a dispensing office to the computer at a factory as a digitized string of mathematics which will last for years and can be reconstructed on demand.
Hopefully, the progression of technology will also be accompanied by a heightened awareness of the importance of the counseling and the auditory rehabilitation process required for a successful hearing aid fitting. Today, what we wishfully call “counseling” is too often little more than “didactic advice-giving.” We need to deliver compassionate care while simultaneously generating the patient’s “story.” It is that story that brings them into your office. The “Platinum Rule” holds true: Patient’s do not care how much you know until they know how much you care.1
There is a need for more personal concern about the patient, and particularly for residents in nursing homes or senior care facilities. In these situations, all too often the patient is inadequately tested, poorly fit, and left to fend for him/herself with minimal instruction, little or no back-up support, few answers to their questions, and not enough follow-up visits. They are not treated with the kind of compassion that their history and predicament warrant. When these people stop communicating, it is like locking the doors to a library. All that wisdom is lost!
In a marvelous book2 on working with the elderly, Barbara Weinstein, PhD, states that the testing and/or evaluation of patients has dramatically changed. She points out that the identification of otopathology is now a sort of “laboratory service” for medicine. She goes on to say that the actual “management of patients” is through auditory rehabilitation and the facilitation of success in the wearing of hearing instruments or the use of assistive listening devices. As the instruments and devices get better—and we get smarter in their use and capabilities—the ultimate beneficiary is the interested patient.
When we are dealing with the residents of a care facility, rehabilitation center, or nursing home, common sense should prevail and counseling or education about the hearing aid should be extended to the patient’s family and nursing staff. If the patient is truly independent, teaching them about the care and use of their instruments is a good idea. But, if they are not, the same care and compassion is the need—and the right—of the caregiver, as well.
Conclusion
The modern digital hearing instrument is the most advanced and sophisticated device ever invented for the facilitation of human communication for those with hearing problems. However, these devices are not intuitively self-explanatory. The learning curve for practitioners, in fact, is quite steep. It is not practice that makes perfect; it is perfect practice that makes perfect. Until the hearing care field starts striving and moving closer to this vision of perfection, we will be stuck knowing less and less about more and more.
Acknowledgement
This article was adapted with permission from an article that appeared in The Hearing Professional (July-August 2003).
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References
1. Hansen V. The Platinum Rule, protocol and process. Hearing Review. 2001;8(4):28-33, 84.
2. Weinstein B. Geriatric Audiology. New York: Thieme Medical Publishers Inc; 2000.
Correspondence can be addressed to HR or Jay B. McSpaden, PhD, PO Box 1043, Jefferson, OR 97352; email: [email protected].
