Inside the Research | September 2020 Hearing Review

By Douglas L. Beck, AuD

Michael Valente, PhD, has been one of the leaders in the profession of audiology. As professor of Otolaryngology-Head and Neck Surgery, and the director of Adult Audiology at Washington University School of Medicine in St Louis, Dr Valente is the author and co-author of four books, and is a well-known authority on audiologic testing, hearing aid fitting, research, and single-sided deafness. Additionally, as a clinical researcher who regularly sees patients, he has shared his practical knowledge and skills with the profession—while serving as a fantastic mentor to students for decades.

As a long-time contributor to HR and many other publications, we recently learned that Dr Valente was retiring, and decided to conduct an “exit interview” with him.

Beck: Good morning, Michael. It is always a joy to speak with you!

Valente: Good morning, Doug. Thanks for the invitation!

Beck: So, here we are, June 2020, and after a couple of decades of me seeking your wise and professional counsel, you will retire on July 31.

Valente: Absolutely, that’s the plan.

Beck: Please review for me: How long have you been an audiologist, and how long have you been at Washington University?

Valente: I’ve been an audiologist for 45 years and I’ve been at Wash U for 34 years.

Beck: I believe you and I met about 33 years ago, when we co-founded the Missouri Academy of Audiology (MAA) along with 5 or 6 other audiologists…and I recall being very impressed. You were extremely well-versed, and you had such a deep understanding of the issues and the political, academic, and educational implications—not just with regard to forming the MAA, but with regard to the AuD movement, which was also happening at that time. I would argue the AuD movement was the largest single issue in audiology from about 1988 through about 2005.

Valente: Those were great days. We were really thinking hard, innovating, pushing back borders, and we were literally changing the audiology world.

Beck: I agree, and frankly, we owe you a huge debt of gratitude for your insights, knowledge, and leadership during those extraordinarily difficult and trying times.

Nonetheless…I also recall a little about the struggles you faced as a child, and I wonder if you’d share some of those with our readers?

Valente: Sure, Doug. Well, as you know, and as my accent may reveal, I grew up in Brooklyn, New York. I usually preface these stories by stating that I don’t know 100% of the facts, but the following is based on what I recall, and what I’ve been told…My sister and I wound up in an orphanage when I was 3 and she was 6 years old. The orphanage was in Far Rockaway, New York. For those not familiar, that’s south of JFK airport and it’s actually on Long Island. I had two brothers, too. They stayed with my father in Brooklyn. We were in the orphanage for 5 years. From the time I was 8 years old until I went to college, I was in a wide variety of foster homes.

Beck: And during that whole time you lived in Brooklyn?

Valente: Yes, Brooklyn and various places across Long Island.

Beck: Where did you go to high school?

Valente: Westbury Long Island and Hicksville Junior High. As you know, Doug, one of my classmates was Billy Joel. Of course, we really just shared some space and time. I didn’t really know him and he didn’t really know me, but it’s a fun recollection.

Beck: There must’ve been something in the Hicksville Junior High water supply, because you each went on to fame and fortune! Billy Joel graduated from Hicksville High School, so you each went separate ways— more or less like the lyrics to his song “James.” Maybe he wrote that about you?

Valente: Probably not!

Beck: OK, fair enough. And then after high school you went to a community college?

Valente: Yes, that’s right. Honestly, as a foster child, I had no money at all. Nassau Community College was substantially less expensive than a standard 4-year college. So I started there and after two years, I matriculated to Adelphi University, a private college on Long Island. I was majoring in history and wanted to be a high school teacher, but there were no jobs available for high school teachers, so I had to pivot. I thought about law school, but didn’t pursue that.

One evening I was at the Salty Dog bar and I ran into a guy who was the Director of Speech Pathology at a hospital on Long Island. He told me about Speech Path. Well, to make a long story short, I received a scholarship and went on to study speech pathology, but I never really like it. It was too “blah.” Not exciting enough, not for me. I didn’t like lesson plans, or pushing ping pong balls across a table…

Beck: And so, two things: the Salty Dog is on Third Avenue in Bay Ridge, Brooklyn. It’s still there. It has a vintage firetruck inside. That says it all. And with regard to Speech Path, of course, your analysis was exactly right 45 years ago. And so before we both get inundated with emails, I would like to add and clarify that you and I both share a deep admiration for Speech Language Pathology in 2020!

Valente: Yes, good point!

Beck: OK, so you had a degree in SLP and then went into audiology?

Valente: Exactly. I had the good fortune to meet Roy Sullivan, PhD, while at Adelphi, and he took me under his wing and urged me to get a PhD, which I did. I attended the University of Illinois at Champagne-Urbana. I was there for three years and I graduated in 1975.

Beck: And I have to add that Roy is one of the unsung heroes in audiology. I recall reading his very clever and insightful articles and commentaries over at least three decades, including several in HR. Very creative guy.

And then you had the good fortune to go to Washington University, where Margaret (Margot) Skinner, PhD, was the Director of Adult Audiology?

Valente: Yes…but I was teaching at the University of Missouri at Columbia, when I got the call from Dr Skinner. Margot was moving on to create the cochlear implant program at Wash U, and she asked if I would be interested to interview for her position in 1986. I was!

Beck: And for those who don’t recall, 1986 was the year the FDA approved cochlear implants for adults, and so that was a pivotal year for the profession—and a progressive move for Wash U.

Valente: Exactly.

Beck: So you and your colleagues at Wash U, and with the Department of Otolaryngology and with collaboration from the Central Institute of the Deaf (CID), built one of the premier AuD programs in the United States. As such, it almost goes without saying that the Audiology Department at Wash U is exemplary and follows Best Practice guidelines from the AAA and ASHA.1-3 Of note, I hasten to add, you were the lead author on those foundational documents.

Valente: Thanks Doug. That’s right. Those BP statements are the essence of what we’re supposed to do as professionals for all the right reasons. And as you and I have discussed many times,4 the majority of hearing care professionals (HCPs) simply don’t follow BP statements.

Beck: And the question which often follows these revelations is how many, or what percentage, of all HCPs (dispensers and audiologists) follow the BP guidelines from ASHA, AAA, or IHS? My best guess is 20%. And although I absolutely hate to say this, I suspect many HCPs have never even read the BP statements or the Ethical Guidelines. To be clear, the professional HCP groups with the largest memberships in the USA have assembled subject matter experts with specific knowledge about how to evaluate, fit, program, counsel, and rehabilitate people who might benefit from amplification, and those same national groups have identified ethical protocols; yet many professionals remain in the dark, despite being members of one or more of these associations.

Best Practices and “Dr Valente’s Greatest Hits”:

• Thorough audiologic evaluation;

• Needs Assessment, including unaided speech recognition in noise and perhaps an unaided questionnaire assessing the patient’s perception of his/her unaided performance in a variety of listening situations;

• Hearing Aid Evaluation to determine which hearing aids, earmolds, and accessories to order;

• Coupler measurements of the ordered hearing aids to verify they adhere to manufacturer specifications, which include assessing the directional microphones and noise reduction;

• A Hearing Aid Fitting which must include real-ear measures (REM) and aided speech-in-noise testing, and

• Validation measures to assess outcomes.

Source: Beck DL. Best practices in hearing aid dispensing: An interview with Michael Valente, PhDHearing Review. 2017;24(12):39-41. See AAA, ASHA, and IHS for full Best Practice guidance documents.

Valente: You’ve just uncovered the most important issues in all of hearing healthcare—Best Practices and ethical professional behavior—neither of which are particularly pleasant to talk about. But let’s do that!

Beck: Well, you’re the interviewee, and the interview is about you. But OK, I’ll share my personal thoughts to get us started. My thoughts are that if it is clearly ethical to follow the BP guidelines of the associations we join, then it seems one might argue it is unethical not to? Of course, morals are what we believe and how we act as individuals, but ethical behavior is, by definition, prescribed by others, like state licensing agencies, the associations and professional groups, as well as social and religious organizations and more. And so it seems to me that if we as individuals join a group of professionals, we’re obligated to adhere to their BP and ethical guidelines.

In the case of HCPs and adult amplification, it is stated in AAA, ASHA, and IHS organizational and professional documents that certain things should be done, such as speech-in-noise testing (using calibrated signal-to-noise ratios), as well as real-ear probe-mic measures to ensure the hearing aid has responded correctly to the settings we’ve dialed-in, and of course, listening and/or communication assessments are a part of BP, too. Do you agree?

Valente: Absolutely. HCPs are responsible to follow their association’s BP guidelines and their ethical guidelines, too. In [the September/October 2009] Audiology Today, Catherine Palmer, PhD—who is now president of AAA—stated “We are all responsible for our profession and must not tolerate behavior that would harm our collective reputation…[and if] we talk about ethical practice, we have to be comfortable saying that there are hearing health-care professionals who are not practicing ethically.” Further, she noted “…an ethical practitioner will follow the best practices supported by evidence and published by their professional organizations.”5 So that’s pretty clear.

To me, it seems reasonable that those who don’t follow national Best Practice and Ethical guidelines should probably lose their license. We really need to think this through and maybe an analogy is useful here. Would you want to have brain surgery by a neurosurgeon who didn’t follow the Congress of Neurological Surgeons BP guidelines, or a dentist, or an Ob-Gyn, or an orthopedic surgeon who didn’t follow their respective BP guidelines? No, I don’t think any of us would choose that.

And from the consumer/patient perspective, they expect the licensed healthcare professional to deliver BP services in an ethical manner. They deserve it and they’re paying for it, and that’s why we have licensing boards in every state—to protect the consumer/patient!

Further, there is a great example of mandating BP found in the National Health Service (NHS) in the UK. Not only do they require real-ear probe-mic measures, but for the practitioner to be reimbursed, the hearing aid response has to hit target within 5 dB at 2000 Hz, and has to be within 8 dB at 4000 Hz.

I would love to see that idea take root here, but I doubt it could happen in the United States. Hearing aids dispensed in the USA are sometimes a little like the wild west…the practitioner can sell whatever they want and fit to whatever protocol they like or find expedient. There are precious few outcomes-based measurements and reports required here, and that’s to our disadvantage—and to the disadvantage of our patients.

Beck: That’s a powerful argument.

Valente: And there’s more, Doug. You’ve been saying this for many years: the necessity of hearing aids is not determined by an audiogram; instead, it is determined by an entire audiometric evaluation, which includes a case history, listening/communication assessment, aural rehabilitation, and more.6 Simply acquiring the least common denominator (air, bone, and speech in quiet) is not Best Practice and does not serve the patient well.

Beck: And to be clear, you’re talking about assessments, such as COSI, APHAB, HHIA or HHIE, IOI, or similar measures?

Valente: Yes. And there are many other options: the PACA, the SSQ, etc. These assessments tell you much more than thresholds.7 They reveal how the patient is getting by with the hearing they have, how much difficulty the individual is experiencing, where that difficulty is occurring, how often it occurs, and importantly, what their individual goals are! And, as we all know clinically, their goals are rarely to make sound louder; their goals are most often to understand speech in noise better. Pure tones are very important—no one is arguing they are not. But the point is pure tones are just one measure of auditory perception, and they don’t reveal all the information we need to assess and treat patients.

Further, each hearing aid is supposed to be measured in a coupler to make sure it is operating correctly and within spec. One simply cannot do a listening/biologic check to assure the hearing aid is functioning properly. Even the most experienced HCP cannot listen to and accurately quantify gain using soft, medium, and loud inputs; or differentiate total harmonic distortion at 3% versus 6%; or reveal whether the compression circuit is working at a 1.8 versus 2.4 compression ratio. We have tools that we need to use to assure maximal quality for the patient. Just like a dentist must have drills, suction, a proper reclining chair, and more…we cannot do our jobs properly unless we have and use the tools of our profession.

Beck: And, therefore, we have BP statements.

Valente: Correct!

Beck: One push-back I often get is HCPs telling me they cannot afford a test box or a real-ear system.

Valente: Well, then honestly—and I don’t say this to be mean—if they cannot afford to do a procedure as prescribed by AAA, ASHA, and IHS, then perhaps they should not be in business. We would never accept an optometrist, or a general practitioner, or a plumber, or a mechanic, or a physical therapist, or a roofer not doing their job in accordance with BP and the ethical guidelines of their field because they cannot afford it. That is unacceptable. If a roofer is skimping on shingles and nails to cut costs, they’re a lousy roofer. Likewise, if any of those licensed professionals told us they cannot afford to do it right—so they’ll “just do the best they can”—then patients shouldn’t be under their care. HCPs need to adhere to that same standard. I think that, as professionals, we often fail to convey that the largest portion of the hearing aid cost is for professional services in accordance with BP and our expertise, similar to dentists, neurosurgeons, urologists, and more.

Beck: OK, so as if the above notes weren’t controversial enough, let’s talk about over-the-counter (OTC) hearing aids and how Wash U is handling that?

Valente: Sure. We think OTC (when it is finalized) might be satisfactory for some people with normal thresholds or perhaps an audiometrically derived mild hearing loss (as opposed to a self-perceived mild-moderate hearing loss).7,8 Of note, the issue is, as we discussed above, what are their communication and their listening needs? What are their goals? Regardless, it seems the majority of patients who are likely to pursue OTC are not patients we are currently serving. However, if you can get them to your office, you might develop a relationship, and you might be able to help them. When we have patients who say they love Wash U, they love the audiology department, they really want the hearing aids, but they cannot afford them, we have an entry-level alternative we can offer them. They can get two professionally selected and fitted hearing aids for less than $1000, including real-ear and coupler measures…and so we think we’re very competitive, even for the serious OTC shopper.

RELATED CONTENT: Coupler and real-ear performance between PSAPs and hearing aids. (November 2018 Hearing Review) by Adam Voss, AuD, Kristi Oeding, AuD, A.U. Bankaitis, PhD, John Pumford, AuD, and Michael Valente, PhD

Beck: That’s an interesting approach. Tell me more about that, please?

Valente: We’ve been offering the entry-level alternative for about 18 months. Of note, we usually fit about 72 hearing aids per month, so we’ve got a large data base. Only 7% of all the patients who have been professionally tested and have scheduled a Hearing Aid Evaluation choose the entry-level alternative when given all the options available. My suspicion is that down the road, most of the people who choose entry-level devices, if they have been professionally serviced, will come back for better technology at some point.

Beck: I like your entry-level alternative; it makes sense. What I am opposed to is having a counter-top display with multiple hearing aids ranging from perhaps $199 to $399 each…no audiogram, no consultation, no professionally set realistic expectations or counseling…just “buy the widget” and leave. I think the OTC approach without professional involvement is just not going to be beneficial enough for most people with substantial hearing and/or listening problems. But I agree, for some people with minor complaints and minimal problems, OTC might be all they need. Then again, people with minor complaints and minimal problems rarely seek our help!

Valente: Right, and even if they do, they wait about 10 years to do so!

Beck:   Yes, we generally talk about patients waiting 7 years to act on their hearing or listening problems, but this July, Almufarrij et al9 noted it takes about 10 years to seek help. Further, similar to your 2018 research,8 they reported direct-to-consumer (DTC) products varied widely in quality. And of note, the more expensive the product was, the closer it came to target values. They also reported that none of the 28 DTC products they tested “could match the NHS (standard) hearing aid in terms of both appearance and performance…” However, OTC and DTC products will certainly improve over time.

Valente: I agree. But as long as the HCPs improve their standard of care, practice Best Practices and ethical protocols, and they provide excellent diagnostic services and products at all price ranges, I think the future for the HCP is brighter than ever!

Beck: OK my friend. Thank you for sharing your thoughts and for a great discussion. I wish for you and your family a joyous and healthy retirement!

Valente: Thanks Doug. It’s always a joy working with you, and I hope to see you soon!

References

1. Valente M, Bentler R, Kaplan HS, et al. Guidelines for hearing aid fittings for adults. Am J Audiol. March 1998;7:5-13. doi:10.1044/1059-0889.0701.05

2. Valente M, Abrams H, Benson D, et al. Guidelines for the Audiologic Management of Adult Hearing Impairment. 2006. Available at: https://audiology-web.s3.amazonaws.com/migrated/haguidelines.pdf_53994876e92e42.70908344.pdf

3. Valente M, Barninger KH, Oeding K, et al. American Academy of Audiology Clinical Practice Guidelines: Adult Patients with Severe-to-Profound Unilateral Sensorineural Hearing Loss. June 2015. Available at: https://www.audiology.org/sites/default/files/PractGuidelineAdultsPatientsWithSNHL.pdf

4. Beck DL. Best practices in hearing aid dispensing: An interview with Michael Valente, PhD. Hearing Review. 2017;24(12):39-41.

5. Palmer CV. Best practice: It’s a matter of ethics. Audiology Today. 2009. Sept/Oct:31-35.

6. Beck DL, Danhauer JL, Abrams HB, Atcherson SR, Brown DK, Chasin M, Clark JG, De Placido C, Edwards B, Fabry DA, Flexer C, Fligor B, Frazer G, Galster JA, Gifford L, Johnson CE, Madell J, Moore DR, Roeser RJ, Saunders GH, Searchfield GD, Spankovich C, Valente M, Wolfe J. Audiologic considerations for people with normal hearing sensitivity yet hearing difficulty and/or speech-in-noise problems. Hearing Review. 2018;25(10)[Oct]:28-38.

7. Humes LE. What is “normal hearing” for older adults and can “normal-hearing” older adults benefit from hearing care intervention? Hearing Review. 2020;27(7):12-18.

8. Voss A, Oeding K, Bankaitis AU, Pumford J, Valente M. Coupler and real-ear performance between PSAPs and hearing aids. Hearing Review. 2018;25(11):10-18.

9. Almufarrij I, Dawes P, Munro K , Stone M, Dillon H. Direct-to-consumer hearing devices: a need to combine cosmetic appeal with device capabilities. July 1, 2020. Available at: https://www.entandaudiologynews.com/features/audiology-features/post/direct-to-consumer-hearing-devices-a-need-to-combine-cosmetic-appeal-with-device-capabilities

Douglas Beck, AuD

About the author: Douglas L. Beck, AuD, is the Vice President of Academic Sciences at Oticon Inc, Somerset, NJ. He has served as Editor in Chief at Audiology Online and as Web Content Editor for the American Academy of Audiology (AAA). Dr Beck is an Adjunct Clinical Professor of Communication Disorders and Sciences at the State University of New York, Buffalo, and also serves as Senior Editor of Clinical Research for The Hearing Review’s Inside the Research column.

CORRESPONDENCE can be addressed to Dr Beck at: dbec@oticon.com