Part 2: Fundamental questions about verification, validation, and hearing aid delivery
This is Part 2 of a two-part perspective on fundamentals in practice management and patient care. Part 1 dealt primarily with the rather humbling idea that the most important—and usually least trained—member of your general office staff is the person who answers the telephone.1 Although one may expend several thousands of dollars on professional training, special equipment, office location, and ambience, and then even more in marketing just to get the phone to ring, it’s ironic that the greatest variable in your “practice revenue equation” is how well your receptionist’s mother taught them to answer the telephone—and how well they remember those rules of politeness when addressing your patients every day. If you can swallow hard and accept this fact, then training receptionists and/or front-office personnel while giving them incentives for top-notch performance will greatly add to the success of your business/practice.
|Jay B. McSpaden, PhD, CCC-A, BC-HIS, is an audiologist who retired from private practice and currently works part-time as a hearing instrument specialist in Jefferson, Ore.|
Part 2, presented here, takes up some important clinical questions, including verification, validation, and aural rehabiliation.
Moving On to the Back Room…
As demonstrated above and in Part 1 of this article, it’s the basic questions like What kinds of messages are my patients receiving when they call our office? that can become epiphanies for your dispensing practice.
Similarly, too rare are the times we actually ask ourselves questions like: Why am I doing this test? Why am I doing it this way for this patient? Why am I doing it in this order within my armamentarium? Too often, the most truthful answer is “Because that’s the way I’ve always done it” or “That’s the way it was taught to me.” If that’s the honest answer, then we’re dooming ourselves to practice the history of our profession, as opposed to the current state-of-the-art standards of patient care.
We cannot permit ourselves to provide patients with 2010’s hearing aid technology using 1980’s fitting methods. It’s not fair to our patients, our professions, or even ourselves as hearing care providers.
Verification and validation. Perhaps, nowhere is this more evident than in the area of hearing aid verification measures. Many states require verification and validation, but only about 23% of hearing care professionals around the country actually perform them on a routine, patient-by-patient basis.1 Hearing instrument manufacturers will tell you that 63% of all hearing aids dispensed in the United States come from a professional who has a Master’s degree in Audiology or better. And those same manufacturers will candidly tell you that 80% to 85% of all hearing aids returned for credit are still set on the “First Fit” setting. It seems clear, in these cases, that it was the audiogram that was fit, rather than the patient. In my opinion, regardless of a professional’s education or professional degree, this does not constitute a professional fitting!
New research into our aging population shows that not only is hearing loss age related, but success in rehabilitation may be age dependent as well. Men and women tend to have, at least statistically, different types and amounts of hearing loss. It is also possible that attack and release times, compression ratios, and UCLs are dependent on age, gender, and cognitive status.
There is nothing magical about manufacturers’ “First Fit” algorithms; the programming is (hopefully) based on normative data from very large “n’s”—or sample sizes—meaning that the hearing aid is initially fit for “the typical hearing aid user and his/her hearing loss” and not necessarily for any given individual. So, if a patient is lucky enough to fall nicely into the mid-portion of that sample’s “bell curve,” the First Fit algorithm should work quite well. But studies have also shown that few manufacturers’ software accurately predicts real-ear data.2 Also, you’ll notice that the manufacturers don’t (yet) request information involving the patient’s age, gender, occupation and lifestyle, cognitive status, dexterity level, first-time versus experienced user versus repair, etc, for the purpose of integrating this information into the actual hearing aid programming. There is not enough research and data to support doing so.
However, that doesn’t limit the professional from keeping all of these things in mind during the selection, fitting, and verification process. As another example, we also know that, for patients with tinnitus and hearing loss, certain strategies (eg, disabling the microphone noise suppression circuit) can allow for a sub-audible sound to act as a masker. These are the “little things” that can make a world of difference to hearing aid users.
The standard for verifying the accuracy of a hearing aid fitting is to measure the acoustic signal generated by the hearing aid in the patient’s ear canal. In my view, verification and validation can be done with real-ear measurement, as well as live speech mapping, aided-versus-unaided speech discrimination, and hearing-in-noise tests. It matters little if one prefers to use COSI, APHAB, QuickSIN, HINT, or other verification/validation measures within a practice; what does matter is that one analyzes the success of each fitting from several aspects, then makes changes when improvement is warranted and/or beneficial to the patient. Of course, these tests and subsequent fitting decisions can also be influenced by objective data, including tympanometry results3 and acoustic middle-ear muscle reflex threshold measurements converted into dBSPL.4
However, our professional services cannot be done with wishful thinking or good intentions alone. We need to support all of our fittings with evidence that the user is receiving benefit from the devices. In fact, in some states, it’s the law!
Hearing aid delivery. The delivery of the hearing instrument is not the end of the process; it is the beginning. The presentation case in which the hearing aid is given to the new user does not contain “immaculate perception” about how to use it or get the most from it. Instead, if patients get the correct aids and fitting, receive the proper instruction, wear the devices diligently, practice daily, and own into their own crucial role in the (re)habilitation process, only then will they succeed in fully overcoming their hearing loss.
In addition to the more traditional aural rehabilitation strategies, I also advocate for having patients do one simple, free, “relatively painless” rehab activity: read aloud for 30 minutes to 1 hour per day for the first 30 days (in some cases 75 days) after they receive their new hearing aids.
If at all possible, they should read to someone. For older patients, I always recommend “borrowing” a grandchild, and reading Dr Seuss to the child in as clear a voice as possible. All of that wonderful alliteration is the perfect thing for re-engaging the language portion of the brain. Plus, it’s fun, and quite often provides a memorable and positive communication experience.
If that’s impossible, reading poetry, funny short stories (eg, James Thurber), the newspaper, or the Bible to one’s spouse or a friend also works well. The point is to combine language and dynamic communication with the process of hearing your own voice.
I admit that I know of no studies to support this recommendation, but I have found this activity to accomplish at least two important objectives, which, in my view, are relatively easy to accept from a clinical perspective:
1) It accelerates acclimation to the sound of the hearing aid user’s own voice—a key step in the acceptance of any new hearing instrument;
2) Because the hearing aid user is reading and speaking the words aloud, they are 100% certain of their meaning—much like captioned television provides visual reinforcement when you are watching in a noisy setting—which is a very different and positive communication situation compared to their previous experiences.
This exercise allows the new hearing aid wearer’s brain to 100% accurately understand speech and regain confidence in their own speaking/listening ability. During the exercise, they are not necessarily listening for content; they are practicing and processing the 44 phonemes in English, using combinations of the 26 letters. If, after a diligent trial, the hearing aid and fitting still fail to benefit them, then the patient deserves your renewed efforts and recommendations—or their money back.
According to Kochkin et al,6 there are approximately 1 million hearing aids sitting in drawers and not being used—accounting for about 12% of all our patients. These hearing aids may be too loud so as to make them overly uncomfortable, or so soft that they effectively function as earplugs in certain environments. Regardless of the problems or the causes, in the view of their owners, these hearing aids don’t provide the benefit they were seeking. As an industry and a profession, we need to drastically reduce this population of dissatisfied users.
In the last few years of his practice, a retired friend and veteran hearing care professional told me that a significant portion of his phone calls and appointments involved, in his words, “correcting other people’s mistakes.” If any of this is a “Surprise” to us, then we need to start asking ourselves some fundamental questions.
- Strom KE. The HR 2006 dispenser survey. Hearing Review. 2006;13(6):16-39. Available at: www.hearingreview.com/issues/articles/2006-06_11.asp. Accessed April 12, 2010.
- Aarts NL, Caffee CL. The accuracy and clinical usefulness of manufacturer-predicted REAR values in adult hearing aid fittings. Hearing Review. 2005;12(12):16-22. Available at: www.hearingreview.com/issues/articles/2005-11_01.asp. Accessed April 12, 2010.
- McSpaden JB. Basic tympanometry in the dispensing office. Hearing Review. 2006; 13(12):16-28. Available at: www.hearingreview.com/issues/articles/2006-11_04.asp. Accessed April 12, 2010.
- McSpaden JB, McSpaden DK. Using acoustic middle ear muscle reflexes and their utility in fitting hearing instruments. Hearing Review. 2008;15(10):44-45. Available at: www.hearingreview.com/issues/articles/2008-09_07.asp. Accessed April 12, 2010.
- McSpaden JB, Brethower LD. Auditory rehabilitation in the digital age. Hearing Review. 2008;15(13):20-22. Available at: www.hearingreview.com/issues/articles/2008-12_02.asp. Accessed April 12, 2010.
- Kochkin S, Beck DL, Christensen LA, Compton-Conley C, et al. MarkeTrak VIII: The Impact of the Hearing Healthcare Professional on Hearing Aid User Success. Hearing Review. 2010;17(4):12-34. Available at: www.hearingreview.com/issues/articles/2010-04_01.asp. Accessed April 12, 2010.
Correspondence can be addressed to HR or Jay B. McSpaden, PhD, at .